>r"* 


o 


1907 


GALL-STONES 


and  their 


SURGICAL  TREATMENT 


BY 
B.  G.  A.  MOYNIHAN,  M.S.  (LoND.),  F.R.C.S. 

LEEDS 


Fully  Illustrated 


PHILADELPHIA-NEW  YORK— LONDON 

W.  B.  SAUNDERS  AND  COMPANY 

1905 


Copyright,  1904,  by  W.  B.  Saunders  &  Company. 


Registered  at  Stationers'  Hall,  London,  England. 


pecifi' 


Ktmedieal 

library 

HOK- 
PREFACE 


This  book  contains  the  material  upon  which  I  based 
a  course  of  lectures  delivered  at  the  Medical  Gradu- 
ates College  in  London  during  April  and  May,  1904. 
It  includes,  I  think,  a  detailed  account  of  the  etiology, 
pathology,  clinical  manifestations  and  operative  treat- 
ment of  gall-stones. 

There  can  be  no  doubt  that  in  the  future  surgical 
treatment  will  be  adopted  more  frequently  and  in  an 
earlier  stage  of  gall-stone  disease  than  has  hitherto 
been  customary.  The  great  and  increasing  importance 
of  the  subject  is,  therefore,  a  sufficient  w^arrant  for  the 
publication  of  a  work  of  this  size. 

I  desire  to  tender  my  thanks  to  the  authorities  in 
charge  of  the  museums  at  the  Royal  College  of  Surgeons 
of  England,  at  Guy's  Hospital,  University  College 
Hospital,  King's  College  Hospital,  and  Charing  Cross 
Hospital,  for  permission  to  photograph  the  specimens 
in  their  charge. 

My  friend.  Dr.  E.  B.  Hulbert,  is  responsible  for  the 
selection  of  these  photographs,  and  I  am  greatly  in- 
debted to  him  for  the  help  he  has  afforded  me. 

The  coloured  and  black  and  white  drawings  have 
been  made  by  Miss  Ethel  Wright.  I  consider  myself 
fortunate  in  having  the  assistance  of  so  able  an  artist. 

B.    G.    A.    MOYNIHAN, 
33  Park  Square,  Leeds, 
August  16,  1904. 


13 


624001 


CONTENTS 


CHAPTER  I.  PAGE 

Anatomy  of  the  Gall-bladder  and  Ducts 17 

CHAPTER  II. 
Varieties  of  Gall-stones 31 

CHAPTER  III. 
The  General  Pathology  of  Gall-stone  Disease 57 

CHAPTER  IV. 
The  Symptoms  and  Signs  of  Gall-stone  Disease 109 

CHAPTER  V. 
The  Special  Symptoms  of  Gall-stone  Disease 140 

CHAPTER  VI. 
Remote  Consequences  of  Gall-stone  Disease 204 

CHAPTER  VII. 

Perforation  of  the  Gall-bladder 226 

CHAPTER  VIII. 
Intestinal  Obstruction  due  to  Gall-stones 252 

CHAPTER  IX. 
Details  of  Preparation  for  Operations  upon  Patients  Suf- 
fering FROM  Gall-stones 270 


CHAPTER  X. 
Operations  upon  the  Gall-Bladder  and  Bile-ducts 293 

CHAPTER  XI. 
Operations  for  Obstruction  of  the  Common  Duct 339 


Index 


0/0 


15 


GALL-STONES 


AND    THKIR 


SURGICAL   TREATMENT. 

CHAPTER  I. 

ANATOMY  OF  THE  GALL-BLADDER  AND  DUCTS. 

The  gall-bladder  in  its  normal  condition  is  pear-shaped, 
and  measures  approximately  3  to  4  inches  in  length  and 
I J  inches  to  i|-  inches  in  width  at  the  fundus,  having 
an  average  capacity  of  i^  ounces.  It  lies  obliquely,  the 
fundus  being  directed  downwards,  slightly  forwards, 
and  to  the  right,  and  touching  the  anterior  abdominal 
wall  at  the  meeting  of  the  outer  border  of  the  rectus 
and  the  costal  arch.  This  point  corresponds  almost 
exactly  with  the  tip  of  the  ninth  rib.  In  the  liver-edge 
there  is  often  a  slight  notch  opposite  the  gall-bladder — 
the  incisiira  vesicalis.  The  neck  of  the  gall-bladder  is 
directed  upwards,  backwards,  and  to  the  left.  All  the 
fundus  is  covered  by  peritoneum,  but  above  this  there  is 
a  bare,  uncovered  surface  which  lies  in  contact  with  the 
liver  in  the  fossa  for  the  gall-bladder.  The  extent  of  the 
peritoneal  investment  varies  much  in  different  individuals. 
In  approximately  five  per  cent,  of  bodies  examined  a 
2  17 


]8        Anatomy  of   the  Gall-bladder  and   Ducts 


Fig.  1. — The  gall-l)laddcr,  bile-ducts,  etc.,  dissected  fmiii  behind. 
The  tipper  small  figure  shcnvs  the  reticulations  of  the  mucous  mem- 
brane  of  the   gall-bladder. 


Anatomy  of   the  Gall-bladder  and  Ducts        19 

distinct  mesentery  exists,  so  that  the  gall-bladder  can 
move,  pendulum  like,  in  the  abdomen.  The  posterior  rela- 
tions of  the  gall-bladder  are,  from  below  upwards,  the 
transverse  colon,  the  duodenum,  and  perhaps  the  pyloric 
end  of  the  stomach.  As  the  gall-bladder  narrows  to  the 
cystic  duct  its  walls  become  slightly  thicker,  and  an  S- 


Fig.   2. — Anatomy  of  the   gall-bladder  and  ducts.      Diagram  altered 
from  Quain  to  show  the  vessels. 


shaped  curve  is  formed.  Be  van  has  pointed  out  that  this 
curve  can  be  entirely  straightened  out  by  dividing  the 
peritoneum  and  connective  tissue  around  the  neck  of  the 
gall-bladder  and  the  cystic  duct.  It  is  just  beyond  the 
first  turn  of  this  curve  that  a  stone  may  be  impacted. 
It  is  then  a  matter  of  great  difficulty  to  force  the  stone 
backwards  into  the  gall-bladder  in  order  to  remove  it. 


20       Anatomy  of  the  Gall-bladder  and  Ducts 

At  the  commencement  of  the  cystic  duct  there  is  a  valvular 
projection  of  the  mucous  membrane  which  can  be  clearly- 
seen  by  looking  into  the  duct  from  the  opened  gall-bladder. 
There  is  a  series  of  similar  valvular  projections  arranged 
along  the  whole  length  of  the  cystic  duct.  The  valves  are 
infoldings  of  the  mucous  membrane  and  are  crescentic  in 
shape ;  they  are  placed  alternately  upon  the  one  side  and 
upon  the  other  of  the  duct.     It  is  generally  said  that  they 


.^^x^^S^  . 


^\ 


Fig.   3. — Gall-bladder,  bile-ducts,  hepatic  and  cystic  artery,  and  portal 
vein  (after  Cabot) . 


are  arranged  "in  spiral  fashion"  in  the  duct,  but  this  is 
erroneous.  The  upper  two,  three,  or  four  valves  are  con- 
stant and  well-marked.  Below  these  the  vah-es  are  often 
imperfectly  formed  or  irregularly  placed.  These  are 
known  as  "the  valves  of  Heister."  The  cystic  duct  is 
about  i^  inches  in  length,  and  it  runs  downwards  and  to 
the  left  between  the  layers  of  the  lesser  omentum  to 
join  the  common  hepatic  duct  in  forming  the  common  bile- 
duct.     The  cvstic  arterv  lies  close  to  the  cvstic  duct, 


The  Common    Bile-duct 


21 


being  above  and  very  slightly  to  the  inner  side.  In 
cutting  across  the  cystic 
duct,  close  to  the  com- 
mon duct,  other  small 
unnamed  branches  of  the 
hepatic  artery  may  be 
wounded.  The  average 
diameter  of  the  cystic 
duct  is  given  by  Bevan 
as  I  inch ;  it  is,  therefore, 
the  narrowest  of  all  the 
bile-ducts.  The  common 
hepatic  duct  formed  by 
the  junction  of  the  right 
and  left  hepatic  ducts  is 
about  2  inches  in  length 
and  one-sixth  of  an  inch 
in  diameter,  being  slightly 
wider  below  than  above ; 
it  runs  downwards  and  to 
the  right  in  front  and  to 
the  right  of  the  portal 
vein.  The  hepatic  artery 
lies  to  its  left. 

The  common  bile-duct 
is  slightly  more  than  3 
inches  in  length,  and  ex- 
tends from  the  point  of 
its  formation  at  the  junc- 
tion of  the  cystic  and 
hepatic  ducts  downwards  and  slightly  to  the  right,  to 


V. 


i!s^y 


Fig. 


4. — The     cystic,     hepatic,    and 
common  ducts  (Testut). 


2  2        Anatomy  of  the  Gall-bladder  and  Ducts 

end  with  the  canal  of  Wirsung  in  the  ampulla  or  diver- 
ticulum of  Vater.  The  ampulla  of  Vater  opens  upon 
a  papilla,  the  "papilla  major"  of  Santorini,  which 
can  be  felt  as  a  small  shot  in  the  mucous  membrane 
of  the  second  portion  of  the  duodenum,  about  4  inches 
from  the  pylorus.  Examined  from  the  opened  duo- 
denum, the  termination  of  the  common  duct  and  of  the 
pancreatic  duct  is  difficult  to  see.  It  is  far  more  readily 
recognised  by  touch.  The  papilla  is,  however,  generally 
placed  upon  a  vertical  ridge  of  mucous  membrane, 
the  plica  longitudinalis,  which  is  readily  distinguished 
from  the  valvulae  conniventes,  whose  folds  run  at  right 
angles  to  it.  The  lower  part  of  this  fold,  that  below  the 
papilla,  is  always  better  marked  than  the  upper  part, 
which  may  be  entirely  absent.  This  lower  part  is  some- 
times described  as  the  "fraenum  carunculae."  The  rela- 
tions of  the  common  duct  are  surgically  of  the  greatest 
importance. 

Three  portions  of  the  duct  may  be  described : 

1.  Supraduodenal. 

2.  Retroduodenal  or  pancreatic. 

3.  Transduodenal  or  interstitial. 

The  first,  or  supraduodenal,  portion  is  approximately 
i\  inches  to  i^  inches  in  length.  It  extends  from  the 
formation  of  the  common  duct  by  the  junction  of  the  cystic 
and  hepatic  ducts  to  the  posterior  surface  of  the  duodenum, 
where  it  comes  in  contact  with  the  pancreas.  This  portion 
lies  in  the  free  edge  of  the  gastro-hepatic  omentum ;  to  its 
left  is  the  hepatic  artery,  and  behind  both  lies  the  portal 
vein.  Along  the  duct  are  two,  three,  or  four  lymphatic 
glands.     The  gastro-hepatic  omentum  containing  these 


The  Common   Bile-duct 


23 


structures,  in  addition  to  lymphatic  vessels  and  nerves, 
forms  the  anterior  boundary  of  the  foramen  of  Winslow. 
In  a  normal  subject  the  foramen  will  permit  the  passage 
of  two  fingers,  but  in  patients  who  have  suffered  from 


Fig.   5. — Shows  the  structures  in  the  gastrohepatic  omentvim  and  a 
transverse  section  at  the  level  of  the  foramen  of  Winslow  (Testut). 


cholelithiasis  the  foramen  may  be  narrowed,  or  even  en- 
tirely obliterated  by  adhesions. 

The  second,  or  retroduodenal,  or  pancreatic  portioii  is  about 
I  inch  to  i^  inches  in  length.     It  lies  in  close  contact  with 


24        Anatomy  of  the  Gall-bladder  and   Ducts 

the  pancreas,  being  either  in  a  groove  or  within  a  canal 
in  the  substance  of  the  gland. 

The  exact  relationship  of  the  common  bile-duct  to  the 
head  of  the  pancreas  is  of  the  greatest  importance.  Helly 
has  studied  the  relationship  in  40  cases.  He  finds  that 
the  lower  end  of  the  duct  is  in  contact  with  the  gland  for  a 
distance  varying  from  2  to  7  cm.     In  15  cases  (equivalent 


Fig.  6. — The  portal  fissure,  showing  the  c>stic  and  hepatic  ducts, 
the  portal  vein,  the  Vjranchcs  of  the  hepatic  artery,  and  lymphatic 
glands  (Testut). 


to  37.5  per  cent.)  the  duct  was  placed  in  a  groove  on  the 
posterior  surface  of  the  pancreas ;  in  2  5  cases  (equivalent 
to  62.5  per  cent.)  the  duct  was  completely  surrounded  by 
the  substance  of  the  gland. 

Bunger  (Beit.  z.  klin.  Chir.,  Bd.  39,  Heft  i)  has  made 
dissections  in  58  subjects.  In  55  he  found  that  the  com- 
mon bile-duct  ran  through  the  substance  of  the  pancreas, 


The  Common    Bile-duct 


25 


and  in  only  3  was  it  uncovered.     The  average  length  of 
its  course  through  the  gland  was  2  cm. 

In  20  cases  in  w^hich  I  dissected  out  the  whole  length  of 
the  common  duct  I  found  in  every  instance  that  the  pan- 
creas, after  dissection,  hid  some  part  of  the  common  duct 


Fig.   7. — The  common  bile-duct,  seen  from  behind. 


from  view  when  looked  at  from  behind.  The  separation 
of  the  duct  from  the  tissue  of  the  pancreas  could  be  effected 
in  7  without  any  apparent  damage  to  the  structure  of  the 
gland,  the  duct  lying  in  a  groove  therein;  in  13  the  duct 
was  so  embedded  that  the  lobules  of  the  gland  had  to 
be  divided  before  the  common  duct  could  be  exposed. 


26       Anatomy  of  the  Gall-bladder  and  Ducts 


h- 


It  may,  therefore,  be  stated  that  in  two  cases  out  of 
three,  on  the  average,  this  portion  of  the  common  duct 
is  surrounded  completely  by  the  tissue  of  the  pancreas, 
and  that  to  reach  the  duct  from  behind,  the  substance  of 
the  gland  would  have  to  be  divided. 

The  third,  or  trausdiiodenaU  or  interstitial  portion  in  the 
duct   comprises    that   portion   which,    passing   obliquely 

through  the  wall 
of  the  second  part 
of  the  duodenum, 
on  its  inner  and 
posterior  aspect, 
ends  in  the  divertic- 
ulum of  Vater.  It 
is  about  I  inch  to  | 
inch  in  length. 

The  common 
duct  at  its  termina- 
tion is  in  relation- 
ship with  the  duct 
of  Wirsung.  As  a 
rule,  both  ducts  end 
in  the  base  of  a  conical  cavity  whose  apex  opens  into  the 
duodenum  upon  a  papilla.  The  conical  cavity  is  termed 
the  diverticulum  of  \^ater.  Its  length  varies,  according 
to  Testut,  from  6  to  7  mm.,  and  its  breadth  from  4  to  5 
mm.  Opie  measured  the  length  of  the  diverticulum  in 
89  specimens.  In  11  specimens  in  100  no  diverticulum 
existed.  It  varied  from  zero  to  1 1  mm. ;  its  average  was 
3.9  mm.  In  only  30  instances  was  the  length  of  the 
diverticulum  5  mm.      The  opening  of  the  amjuilla  upon 


Fig.  8. — The  papilla  of  Vater  seen  from 
the  duodenum.  Note  the  overhanging 
fold  and  the  vertical  ridge,  the  frtenum 
carunculae. 


The  Common    Bile-duct  27 

the  surface  of  the  papilla  is  narrow — narrower  than  any 
portion  of  the  duct.  Opie  found  the  average  diameter  of 
the  orifice  to  be   2.5   mm. 

The  actual  size  of  the  diverticulum  and  the  relative 
size  of  the  diverticulum  and  of  its  opening  upon  the  sur- 
face of  the  duodenum  are  of  great  importance  from  a 
surgical  standpoint,  for  if  the  diameter  of  the  opening, 
for  example,  be  3  mm.,  and  a  calculus  4  mm.  in  diameter 


Fig.   9. — Absence   of   ampulla  Fig.    10. — Ampulla    of    Vater 

of  Vater,  showing  separate  open-  with  termination  of  common  duct 

ings   of   common   dvict   and   duct  and  duct  of  Wirsung. 
of  Wirsung  on  the  papilla. 


reach  the  ampulla  from  the  common  duct,  it  may  block 
the  duodenal  orifice,  being  unable  to  pass,  and  will,  there- 
fore, convert  the  common  bile-duct  and  the  pancreatic  duct 
into  a  common  closed  channel.  These  are  the  conditions 
which,  as  shown  by  Opie,  determine  the  incidence  of  acute 
pancreatitis  by  allowing  a  retrojection  of  bile  from  the 
common  duct  into  the  canal  of  Wirsung. 


28        Anatomy  of  the  Gall-bladder  and  Ducts 

The  termination  of  the  two  ducts  in  the  ampulla  is 
surrounded  by  circular  muscular  fibres — the  so-called 
"sphincter  of  Oddi."  These  fibres  are  continuous  with 
the  longitudinal  muscular  fibres  on  the  ducts. 

Variations  from  this  normal  condition  of  the  ampulla 
are  not  common.  The  two  ducts  may  open  separately 
into  the  duodenum,  or  the  canal  of  Wirsung  may  partially 
surround  the  lower  end  of  the  duct,  being  gutter-shaped, 
or  the  papilla  may  be  absent,  and  in  its  place  a  depression 
may  be  seen  on  the  duodenal  wall. 

Diameter  of  the  Duct. — The  duct  gradually  narrows 
from  its  beginning  to  its  end.  According  to  Padula  (Brit. 
Med.  Journ.  Supplement,  Feb.  27,  1904,  p.  34),  the  first 
portion  attains,  with  the  distension  which  produces  injec- 
tion on  the  cadaver,  a  diameter  of  7,  8,  or  even  8^  mm. ; 
the  second  portion  is  never  wider  than  5  mm.,  and  the 
third  portion  than  3^  mm.  A  gradual  lessening  of  the 
diameter  of  the  common  duct  is  therefore  one  of  the  causes 
of  impaction.  A  stone  which  would  pass  along  the  first 
inch  of  the  duct  would  become  wedged  in  the  lower  and 
narrower  portion. 

Access  to  the  common,  cystic,  and  hepatic  ducts  can  be 
best  obtained  by  freeing  them  from  adhesions,  introducing 
the  finger  into  the  foramen  of  Winslow,  and,  by  gentle 
forward  traction,  fixing  that  part  of  the  bile  tract  into 
which  an  incision  is  to  be  made. 

The  lower  part  of  the  common  duct  can  be  reached  in 
one  of  two  ways,  retroduodenal  and  transduodenal.  In  the 
former,  the  duct  is  opened  from  behind,  access  being 
obtained  by  dividing  the  parietal  peritoneum  to  the  right 
of  the  descending  portion  of  the  duodenum.     The  peri- 


The  Common    Bile-duct 


29 


toneum  to  the  left  of  this  incision  is  stripped  up  until  the 
duodenum  is  reached,  and  it  will  then  be  found  a  simple 
matter  to  turn  the  second  portion  of  the  duodenum  over  to 
the  left.  It  is  possible,  in  fact,  to  mobilise  this  portion  of 
the  gut,  reproducing  that  condition  of  free  duodenum  which 


Fig.  II. — Common  duct  seen  from  behind,  showing  lymphatic  glands 
along  the  cystic  and  common  ducts. 


is  normal  in  foetal  life.  The  posterior  surface  of  the  duct 
is  thus  reached.  The  transduodenal  route  opens  up  the 
second  portion  of  the  duodenum  and  exposes  the  papilla. 
The  lower  end  of  the  duct  may  be  defined  by  passing  a 
director  upwards  along  the  duct,  and  by  slitting  the  mucous 
membrane  upon  this.     If  only  the  lower  end  of  the  duct — 


30        Anatomy  of  the  Gall-bladder  and  Ducts 

that  portion  which  lies  within  the  wall  of  the  duodenum — 
is  opened,  there  is  no  need  for  the  introduction  of  stitches. 

The  walls  of  the  gall-bladder  and  the  ducts  consist  of 
peritoneum,  which  forms  only  a  partial  investment  of  a 
layer  of  fibrous  and  muscular  tissue  intermixed,  and  of  an 
inner  layer  of  mucous  membrane,  covered  with  columnar 
epithelium.  The  mucous  membrane  of  the  gall-bladder 
presents  a   finely  honeycombed  appearance. 

Lymphatic  Glands. — The  position  of  the  lymphatic 
glands  around  the  bile  tract  is  a  matter  of  some  importance. 
Mascagni  described  a  gland  as  being  constantly  present  at 
the  neck  of  the  gall-bladder  where  the  S-shaped  turn  is 
being  made  to  the  cystic  duct.  This  gland  is  frequently 
but  not  invariably  present.  Ouenu  describes  two  constant 
glands,  one  larger,  on  the  outer  side  of  the  common  duct, 
at  its  commencement,  and  one  smaller,  a  little  higher  up,  in 
the  angle  between  the  cystic  and  hepatic  ducts.  A  chain 
of  four  or  five  glands  lies  along  the  common  duct.  These 
glands  by  their  enlargement  may  cause  a  blockage  in  the 
ducts,  or  at  the  outlet  from  the  gall-bladder,  and  they 
may,  when  enlarged,  be  so  firm  and  hard  as  to  persuade 
the  operator  that  a  stone  is  surely  present  in  the  duct. 
Dr.  Brewer  has  recorded  a  case  of  Hodgkin's  disease  in 
which  the  enlargement  of  the  glands  along  the  common 
duct  caused  all  the  symptoms  of  obstruction  of  the  com- 
mon duct,  so  that  an  erroneous  diagnosis  of  malignant 
disease  was  made. 


CHAPTER  II. 

VARIETIES  OF  GALL-STONES. 

Naunyn  has  suggested  the  following  classification  of 
gall-stones : 

1.  Pure  Cholesterin  Stones. — These  are  hard,  oval  or 
spherical,  smooth,  pure  white  or  yellowish,  and  trans- 
lucent, rarely  brown  or  green  in  colour.  They  are  gener- 
ally of  the  size  of  a  cherry  or  larger.  On  section,  they 
appear  white  and  crystalline  throughout ;  on  fracture  a 
radiating  striation  is  generally  visible. 

2.  Laminated  Cholesterin  Stones. — These  are  generally 
hard,  but  they  become  fissured  and  cracked  on  desiccation. 
The  surface  may  be  variously  coloured.  In  size  and  form 
they  resemble  the  first  variety,  but  they  are  more  often 
distinctly  facetted.  On  section  they  are  laminated.  They 
consist  of  90  per  cent,  cholesterin ;  in  addition  they  contain 
small  quantities  of  bilirubin-calcium  and  biliverdin-cal- 
cium,   and  carbonate  of  soda. 

3.  Ordinary  gall-bladder  stones — of  various  sizes, 
shapes,  and  colours.  They  rarely  grow  larger  than  a 
cherry  and  are  generally  much  smaller.  They  are  facetted 
and  of  a  brown  or  yellow  or  rarely  of  a  greenish  colour. 
When  first  removed,  they  are  soft  and  compressible,  but 
as  they  dry  they  shrink  and  become  hard.  They  have 
a  hard  shell  and  a  soft  kernel.  No  crystalline  structure 
is  visible. 

31 


32  Varieties  of  Gall-stones 

4.  Mixed  Biiiruhin  Stones. — These  are  usually  as  large 
as  a  cherry  or  even  larger.  They  occur  as  solitary  stones 
or  in  numbers  of  two,  three,  or  more,  and  are  found  in 
either  the  gall-bladder  or  the  ducts,  generally  in  the 
former.  On  drying,  an  outer  layer  or  layers  may  peel 
off  like  a  rind.  The  nucleus,  and  sometimes  the  shell, 
consists  chiefly  of  cholesterin ;  the  rest  of  the  stone  con- 
sists of  bilirubin-calcium. 

5.  Pure  Biliruhin-calciiim  Calsuli. — Of  these  there  are 
two  varieties: 

(c7)  Solid  black-brown  concretions  with  a  nodular  sur- 
face,   generally    compressible    and    conglomerate. 

ih)  Harder  stones,  often  spindle-shaped,  showing  a 
metallic    lustre    on    crushing. 

6.  Rarer  Forms: 

(a)  Amorphous  stones,  resembling  pearls. 

(6)   Chalk  stones,   very   hard   and   prickly  or  smooth 

and  often  containing  a  hollow  in  the  centre, 
(c)  Concretions  formed  around  foreign  bodies,  such 
as  a  worm  of  the  species  Anguillula  (Lobstein),  a 
piece  of  Distoma  hepaticum  (Bouisson),  a  needle 
(Nauche),  the  kernel  of  a  plum  (Frerichs),  small 
particles  of  mercury  (Frerichs),  silk  or  catgut 
sutures  (Homans,  Kehr). 
id)  Casts  of  the  bile  passages. 

Gall-stones  may  be  single  or  multiple.  A  solitary 
calculus  mav  be  found  in  the  gall-bladder,  in  the  cystic 
duct,  or  in  any  part  of  the  hepatic  or  common  ducts. 
A  single  calculus,  when  discovered  during  operations, 
is  nearly  always  impacted  at  some  part  of  the  bile  pass- 
ages.    As  a  rule,  calculi  are  multiple,  and  the  number 


?)'•» 


^ 


4  ♦. 


i 


# 


Fig.    12. — Gall-stones. 
I,   Almost  free  cholesterin:    2,  cholesterin  and  bilirubin-calcium; 
3,  a  stone  removed  from  the  ampvilla  of  Vater;   4,  a  stone  removed 
from  the  coininon  duct;   5,  a  stone  removed  from  the  cystic  duct. 


Varieties  of  Gall-stones  ^3 

of  them  is  sometimes  astonishing.  The  largest  number 
I  have  removed  is  1885.  The  patient  was  a  man  aged 
thirty-eight,  who  suffered  also  from  duodenal  ulcer,  with 


Fig.  13. — Small  black  tuberculated  calculi  of  bile-pigment  em- 
bedded in  mucus,  the  whole  removed  by  operation  from  the  gall- 
bladder of  a  patient  from  whom  a  small  ulcer  of  the  stomach  was  ex- 
cised. From  a  patient  aged  fifty-five,  who  had  suffered  for  several 
years  from  indigestion,  and  who  then  began  to  experience  severe  pain 
about  an  hour  after  food,  and  to  lose  flesh.  A  doubtful  tumour  could 
be  felt,  and  during  attacks  of  pain  the  stomach  hardened  under  the 
hand.  Free  HCl  was  found  present  after  a  test-meal  On  exploration 
the  swelling  was  found  to  be  a  greatly  thickened  pylorus,  and  along 
the  lesser  curvature  was  a  "tumour,"  which,  on  opening  the  stomach, 
proved  to  be  thickening  due  to  a  chronic  ulcer.  The  latter  was  excised 
and  the  edges  closed  by  suture.  Posterior  gastro-enterostomy  was  next 
performed,  and  the  gall-bladder  emptied  of  the  material  shown  in  the 
specimen  and  drained.  Complete  recovery.  (Royal  College  of  Sur- 
geons' Museum,  No.  283  Og.) 


hasmatemesis  and  melasna.  For  this,  gastro-enterostomy 
was  performed.  As  a  matter  of  routine,  I  explored  the 
gall-bladder  and  found  it  packed  with  small  stones,  the 
average  size  being  equal  to  that  of  a  mustard  seed.  There 
3 


34  Varieties  of  Gall-stones 

had  been  no  mention  of  symptoms  of  gall-stone  colic 
before  the  operation,  and  on  subsequent  enquiry  nothing 
that  could  not  be  accounted  for  by  the  duodenal  ulcera- 
tion was  elicited.  Larger  numbers  of  stones  have  been 
found  on  postmortem  examination.  Thus  Frerichs,  in 
a  woman  sixty-one  years  of  age,  found  1950  stones.  Dun- 
lop  (Lancet,  1878),  in  a  woman  of  ninety-four,  found 
201 1.  Morgagni  3000,  Hoffmann  3646,  Langenbuch  4000, 
Naunvn  5000,  and  Otto  7802.  As  a  rule,  it  maybe  said 
that  the  fewer  the  stones,  the  larger  their  size,  and  the 
more  numerous  the  stones,  the  smaller  are  they.  Two  or 
three  large  stones  may  be  present  and  smaller  stones  may 
then  be  found  with  them  in  hundreds.  If  many  small 
stones  are  present,  they  are  generally  rounded  in  shape 
and  smooth  on  the  surface,  but  when  the  stones  are  larger 
than  mustard  seeds,  the  pressure  of  one  against  another 
causes  facetting. 

The  largest  gall-stone  I  have  removed  had  caused  intes- 
tinal obstruction.  Its  diameter  was  i^  inches.  Stones  of 
a  size  far  greater  than  this  are  sometimes  found.  Meckel 
describes,  in  the  Transactions  of  the  Berlin  Academy,  one 
which  was  15  cm.  long  and  6  cm.  thick;  it  completely 
filled  an  enlarged  gall-bladder.  Another  large  stone  is 
depicted  b}^  Hutchinson  in  the  Archives  of  Surger^^ 
July,  1 89 1,  and  by  Mayo  Robson  (Diseases  of  the  Gall- 
bladder and  Bile-ducts,  second  edition,  page  151).  It 
weighed  3  ounces  5  drams. 

When  a  number  of  stones  are  present  in  the  gall-blad- 
der they  are,  as  a  rule,  of  the  same  formation.  Hein 
found  variations  in  the  chemical  constitution  in  28  out 
of  632  cases. 


The  Formation  of  Gall-stones  35 

In  326  cases  of  gall-stones  of  which  Riedel  possessed 
accurate  information,  in  56  there  was  i  stone;  in  29 
there  were  2  stones ;  and  in  1 7  there  were  3  stones.  The 
stones  were  few  in  number,  were  generally  large  in  size, 
and  vice  versa. 


THE   FORMATION   OF   GALL-STONES. 

From  the  days  of  Galen  up  to  comparatively  recent 
times  the  belief  was  universal  that  gall-stones  were  the 
result  of  the  coagulation  of  bile,  induced  by  the  increase 
of  heat  in  the  liver. 

Morgagni,  and,  after  him,  Meckel  von  Hemsbach,  at- 
tributed a  causative  influence  to  a  chronic  catarrh  of  the 
mucous  lining  of  the  gall-bladder  and  bile-ducts.  The 
recent  investigations  of  Naunyn,  Gilbert,  Mignot,  and 
others  have  thrown  light  upon  many  of  the  circumstances 
necessary  to  the  formation  of  gall-stones  in  animals  and 
in  men. 

r  The  two  chief  constituents  of  gall-stones  are  choles- 
terin  and  bilirubin-calcium.  The  origin  of  these  two 
substances  seems  now  to  be  definitely  settled.  Budd, 
in  1845,  was  the  first  to  suggest  that  the  cholesterin  of 
gall-stones  was  derived  from  the  mucosa  of  the  gall-blad- 
der. Bristowe,  in  1887,  supported  this  view,  and  Naunyn 
gave  it  strenuous  advocacy  in  1892.  It  has  now  been 
shown,  by  much  careful  work,  that  these  two  substances 
are  derived  from  the  mucosa  of  the  gall-bladder;  that 
for  their  production  certain  alterations  are  necessary, 
such,  for  example,  as  slight  inflammation  with  desqua- 
mation   of   the    epithelium    (a    condition   which    Meckel 


36  Varieties  of  Gall-stones 

called  "  lithogenous  catarrh"),  and  that  in  all  probability 
this  change  is  accompanied  by  an  increased  outpouring 
of  mucus  from  the  glands. 

In  the  great  majority  of  cases,  therefore,  gall-stones 
are  formed  in  the  gall-bladder.  When  found  in  the 
ducts,  even  in  the  hepatic  ducts,  or  the  intrahepatic 
ducts,  they  are  formed  in  the  gall-bladder  and  have  mi- 
grated thence.  Gall-stones  may,  however,  without  ques- 
tion, form  in  the  ducts  primarily,  as,  for  example,  in  the 
intrahepatic  ducts  in  cirrhosis  of  the  liver. 

The  slight  forms  of  cholecystitis  necessary  to  the  forma- 
tion of  gall-stones  may  be  produced  by  the  injection  of 
chemical  irritants  into  the  gall-bladder,  or  by  the  intro- 
duction of  micro-organisms. 

Herter  (Med.  News,  Sept.,  1903)  has  found  that  the 
injection  of  bichloride  of  mercury,  carbolic  acid,  or  ricin 
into  the  gall-bladder  resulted  in  a  marked  increase  in 
the  cholesterin  in  the  bile.  The  gall-bladder  walls  were 
usually  thickened  (especially  in  the  bichloride  series) 
and  showed  considerable  proliferation  and  desquamation 
of  epithelium,  together  with  congestion  of  the  vessels  of 
the  submucosa.     The  bile  remained  sterile. 

Bacteria. — During  the  last  few  years  much  attention 
has  been  given  to  the  influence  of  bacteria  in  the  pro- 
duction of  gall-stones.  The  microbial  origin  of  biliary 
and  other  calculi  was  first  suggested  in  1886  by  Galippe. 
In  1890  Welch  found  the  bacillus  coli  and  the  staphylo- 
coccus pyogenes  in  gall-stones,  and  in  1896  Hanot  and 
Milan  discovered  the  bacillus  typhosus. 

It  was  formerly  thought  that  the  bile  possessed  a 
mild,   though   perhaps  an    important,  antiseptic   action. 


Bacteria  37 

Letienne  (Arch,  de  Med.  Exp.,  1891),  Mieczkowski  (Mitt, 
aus  den  Grenzgeb.,  Bd.  6),  and  others,  however,  found 
that  micro-organisms  could  be  readily  cultivated  in 
normal  bile,  though  their  rate  of  growth  was  not  so  rapid 
as  in  broth.  The  bile  of  all  animals  and  of  man  is  said, 
under  normal  circumstances,  to  be  sterile.  Rettger, 
W'Orking  under  the  direction  of  Herter,  made  cultures 
from  the  bile  of  six  healthy  dogs,  with  negative  re- 
sults in  every  instance.  Erhardt  divided  the  common 
or  hepatic  ducts  in  several  animals  and  allowed  the  bile 
to  flow  freely  into  the  peritoneal  cavity.  No  signs  of 
peritoneal  sepsis  resulted ;  the  animals  died  after  a  few 
days  of  cholsemia.  If,  however,  the  bile  was  first  in- 
fected by  the  bacillus  coli,  a  septic  peritonitis  rapidly 
developed  and  proved  fatal.  Fraenkel  and  Krause 
(Zeit.  f.  Hygiene,  Bd.  32)  opened  the  gall-bladder  in 
guinea-pigs  and  rabbits,  and  allowed  the  bile  to  flow^  freely 
into  the  peritoneal  cavity,  without  causing  infection. 
Miyake  found  no  organisms  in  the  bile,  in  the  gall-blad- 
der, cystic  and  hepatic  ducts,  in  75  animals  out  of  76. 
He  further  showed  that  the  lower  portion  of  the  common 
duct,  and  the  ampulla  Vateri  in  particular,  invariably 
contained  organisms,  especially  the  bacillus  coli.  In 
dogs  and  in  rabbits  Netter  and  Duclaux  found  the  lower 
part  of  the  common  duct  to  be  inhabited  by  bacteria, 
the  rest  of  the  bile  passages  being  sterile.  Naunyn  and 
Gilbert  found  the  bile  from  the  gall-bladder  removed 
after  death  to  be  sterile.  These  results,  however,  have 
not  been  invariably  confirmed  by  other  investigators. 
Ehret  and  Stolz  (Mitt.  a.  den  Grenz.,  Bd.  7),  using  large 
quantities  of  bile,  so  as  to  increase  the  likelihood  of  the 


38  Varieties  of   Gall-stones 

discovery  of  organisms,  found  that  the  bile  was  sterile 
in  only  about  one-half  of  the  cases  examined.  Fraenkel 
and  Krause  examined  the  bile  in  125  autopsies.  In  105 
cases  the  bile  was  sterile.  Of  these  128,  36  patients  were 
tuberculous.  In  34  of  these  the  bile  was  sterile  on  ex- 
amination by  ordinary  culture  methods.  Eleven  guinea- 
pigs  were  injected  with  the  bile  from  these  patients, 
and  five  well-marked  tuberculous  lesions  were  excited.  It 
is,  therefore,  possible  that  though  the  usual  culture  tests 
may  fail  to  reveal  the  presence  of  micro-organisms,  they 
may,  nevertheless,  be  present,  though  they  are  probably 
few  in  number  and  of  very  slight  virulence.  Very  few 
investigations  have  been  made  from  the  healthy  human 
bile  removed  during  life.  Mieczkowski  collected  the 
bile  from  15  cases  operated  upon  for  diseases  other  than 
cholelithiasis.  In  all  it  was  sterile.  In  23  cases  operated 
upon  for  gall-stones  the  bile  was  infected  in  18.  Petersen 
also  found  that  in  50  operations  for  gall-stones  bacteria 
were  present  44  times;  in  36  the  bacillus  coli  alone  was 
found ;  in  6  it  was  found  in  association  with  the  staphylo- 
coccus aureus,  and  in  4  with  the  streptococcus  pyogenes. 
Hartmann  (Deut.  Zeit.  f.  Chir.,  Bd.  68,  p.  207)  ex- 
amined the  bile  in  46  cases  of  cholelithiasis  treated  by 
operation.  In  36  bacteria  were  found;  in  10  the  fluid 
was  sterile.  In  23  the  bacillus  coli  alone  w^as  found;  in 
3  the  staphylococcus  pyogenes  albus  and  aureus;  in  2 
streptococci ;  in  i  the  staphylococcus  pyogenes  albus ; 
in  2  the  bacillus  coli  with  staphylococcus;  in  3  strepto- 
cocci, with  other  organisms.  Bacteria  were  found  in 
larger  numbers  in  the  bile  removed  from  the  common 
duct  in  cases  of  calculus  in  the  duct.     These  investiga- 


Bacteria  39 

tions  refer  to  the  micro-organisms  found  in  the  bile,  not 
to  those  found  in  the  gall-stones.  The  absence  of  the 
bacillus  typhosus  is,  therefore,  not  so  remarkable  as  it 
might  seem. 

In  ordinary  health  it  is  probable,  therefore,  that  the 
human  bile  is  sterile,  but,  as  Herter  says,  "  Bacteria  are 
likely  to  be  present  in  human  bile  when  there  exist  patho- 
logical conditions  in  parts  remote  from  the  gall-bladder." 
He  points  out,  further,  the  difficulty  of  discovering  such 
organisms  as  the  pneumococcus  and  the  tubercle  bacil- 
lus, which  renders  it  possible  that  the  bile  may  appear 
to  be  sterile  when  in  reality  it  is  infected.  The  bile  re- 
mains sterile,  however,  only  so  long  as  it  flows  unhindered 
through  the  ducts.  Charcot  and  Gombault  first  showed 
that  as  soon  as  the  outward  flow  of  bile  was  hindered  by 
ligature  of  the  common  duct  the  bile  above  the  obstruc- 
tion became  infected.  Sherrington  showed  that  when 
the  bile  is  not  escaping  freely  from  the  common  duct  an 
ascending  infection  from  the  duodenum  speedily  occurs. 

The  connexion  between  typhoid  fever  and  biliary 
infection  has  been  closely  studied  since  Bernheim,  in 
1880,  first  called  attention  to  it.  Hanot  and  Milan,  in 
1896,  found  the  bacillus  typhosus  in  the  centre  of  gall- 
stones of  recent  formation  in  the  gall-bladder.  Chiari,  in 
1893,  found  the  typhoid  bacillus  in  the  gall-bladder  in  19 
out  of  22  cases  of  enteric  fever,  and  Gushing,  in  1898,  found 
that  in  50  per  cent,  of  patients  who  died  of  typhoid  fever 
the  organism  could  be  found  in  the  bile  removed  from  the 
gall-bladder.  Ehret  and  Stolz  compiled  a  table  of  32  cases 
of  typhoid  cholecystitis  which  were  treated  by  opera- 
tion or  recognised  at  an  autopsy.     Of  this  number  in  no 


40  Varieties  of  Gall-stones 

less  than  20  were  gall-stones  present.  Chauffard  found 
that  20  per  cent,  of  cases  of  cholelithiasis  gave  a  history 
of  a  previous  attack  of  typhoid  fever,  and  Gushing  found 
that  30  per  cent,  of  the  patients  operated  upon  at  the 
Johns  Hopkins  Hospital  had  previously  suffered  from 
this  disease.  Gushing  further  called  attention  to  the 
fact  that  in  typhoid  fever  there  may  be  an  active  ag- 
glutinative serum  reaction  towards  the  bacillus  typhosus 
and  the  colon  bacillus  isolated  from  the  gall-bladder. 
The  bile  may  share  the  agglutinati\'e  properties  of  the 
serum. 

Richardson,  in  a  case  of  cholecystitis,  found  the  typhoid 
bacillus  clumped  "as  if  a  gigantic  serum  reaction  had 
taken  place  in  the  gall-bladder."  In  examining  the  bile 
in  fatal  cases  of  typhoid  fever  he  found  large  clumps  of 
bacilli  in  five  cases  out  of  six ;  in  the  sixth  case  the  blood 
serum  had  no  agglutinative  property.  He  injected  0.5 
c.c.  of  typhoid  bouillon  culture,  in  which  clumping  had 
been  produced  by  the  addition  of  typhoid  serum,  into 
the  gall-bladder  of  one  rabbit;  into  the  gall-bladder  of 
a  second  rabbit  he  injected  two  drops  of  ordinary  bouillon 
culture  of  typhoid  bacilli ;  a  third  rabbit  was  used  as  a 
"control."  Four  months  later  all  the  animals  died.  In 
the  first  rabbit  the  gall-bladder  was  contracted  and  a 
rounded  concretion  was  found  within  it;  in  the  second 
nothing  was  found;  in  the  third  there  were  a  number 
of  round  bodies  arranged  in  concentric  rings. 

The  extraordinary  endurance  of  typhoid  organisms 
in  the  gall-bladder  and  bile-ducts  is  shown  by  cases  re- 
corded by  Droba  (Wien.  klin.  Woch.,  1899,  No.  46)  and 
Hunner  (Johns  Hopkins  Hosp.  Bulletin,  1899).     In  the 


Bacteria  4 1 

former  the  bacillus  was  found  seventeen  years  after 
typhoid  fever,  and  in  the  latter  a  purulent  collection 
beneath  the  right  costal  margin  contained  the  bacillus 
of  Eberth  eighteen  years  after  the  occurrence  of  typhoid. 

Successful  attempts  to  cause  gall-stone  formation  in 
animals  have  now  been  made  in  a  large  number  of  cases. 
The  priority  in  this  matter  belongs  to  Gilbert,  though 
Mignot,  in  1897,  preceded  him  in  the  publication  of  re- 
sults. In  1893  Gilbert  and  Domenici  had  noticed  in 
the  gall-bladder  of  a  rabbit  in  which  cholecystitis  and 
cholangitis  had  been  produced  the  presence  of  "petites 
concretions  verdatres,"  but  it  was  not  until  January  29, 
1897,  that  they  obtained  a  small  stone  from  the  gall- 
bladder of  a  dog  that  had  been  infected  with  the  bacillus 
coli.  Gilbert  and  Domenici  had  discovered,  in  1894.  the 
presence  of  organisms,  both  living  and  dead,  in  one- third 
of  the  gall-stones  examined  by  them.  Their  obser- 
vations were  confirmed  by  Hanot,  Letienne,  and  others. 
The  possibility  of  the  penetration  by  organisms  of  stones 
already  formed  was  mentioned  by  Gilbert  and  Fournier. 
Gilbert  in  a  later  communication  has  said  that  the  forma- 
tion of  gall-stones  may  be  protective  in  character,  an 
offending  and  irritating  organism  being  encapsulated  and 
embedded  in  an  innocuous  material. 

The  injection  of  virulent  micro-organisms  into  the 
gall-bladder  is  not  sufficient  to  induce  the  formation  of 
gall-stones  in  the  great  majority  of  experiments.  As  a 
rule,  an  acute  cholecystitis  is  aroused,  and  the  mucosa  is 
so  damaged  by  inflammation  and  ulceration  that  the 
overproduction  of  cholesterin  is  entirely  prevented.  In 
purulent  cholecystitis  occurring  in  man  and  produced 


42  Varieties  of  Gall-stones 

experimentally  in  animals  bile  and  the  pigments  of  bile 
are  entirely  absent.  Mignot  first  pointed  out  the  neces- 
sity of  using  attenuated  cultures.  An  attenuated  culture 
when  injected  produces  a  mild,  subacute  cholecystitis 
which  is  peculiarly  favourable  to  the  overproduction  of 
cholesterin,  and,  therefore,  to  the  formation  of  calculi. 
It  is  found  to  be  of  great  advantage  in  making  the  attempt 
to  produce  cholelithiasis,  to  use  an  organism  that  has 
been  cultivated  for  several  weeks  in  diluted  bile.  Mignot 
in  his  work  obtained  the  following  results  (see  Epitome, 
Brit.  Med.  Journ.,  1898,  p.  92,  article  431) : 

1 .  Foreign  bodies  when  introduced  into  the  gall-bladder 
can  stay  there  for  an  indefinite  time,  provided  they  are 
aseptic,  without  causing  inflammation  or  precipitating 
the  solids  from  the  bile. 

2 .  Foreign  bodies  previously  impregnated  with  virulent 
micro-organisms  cause  a  more  or  less  intense  cholecystitis 
and  precipitate  the  solids  from  the  bile.  As  long  as  the 
bacteria  retain  their  virulence,  however,  they  cannot  form 
a  calculus,  but  only  a  sediment  mixed  with  pus.  This 
precipitate  has  no  tendency  to  cohere  or  to  adhere  to 
foreign  bodies. 

3.  The  bacteria  must  be  attenuated,  not  virulent. 
This  is  best  attained  by  growing  them  for  some  months  in 
bile  to  which  constantly  decreasing  amounts  of  broth  are 
added.  When  sufficiently  attenuated  they  are  no  longer 
pathogenic  when  injected  into  the  cellular  tissue  of  ani- 
mals. By  injecting  these  into  the  gall-bladder,  stones 
are  occasionally  formed,  but  more  often  the  bacteria  are 
washed  out  into  the  intestine.  If,  however,  a  foreign 
body,  especially  if  porous,  such  as  cotton  wool,  be  placed 


Bacteria  43 

in  the  bladder  and  fixed  to  its  wall  to  prevent  expulsion, 
a  stone  is  formed  round  it  with  the  greatest  certainty. 
Five  or  six  months  are  required  for  formation  of  a  per- 
fect calculus. 

Gilbert  and  Fournier  injected  into  the  gall-bladder  of  a 
rabbit  a  culture  of  the  typhoid  bacillus  attenuated  by 
heating  a  bouillon  culture  for  ten  minutes  at  a  temperature 
of  50  per  cent.  Three  drops  of  this  attenuated  culture 
were  injected ;  six  weeks  later  the  rabbit  died.  In  the  gall- 
bladder two  concretions  were  found  adherent  to  the  mu- 
cous membrane.  Sections  of  these  showed  a  central  whit- 
ish portion  from  which  typhoid  bacilli  were  obtained  in 
pure  culture ;  the  shell  was  pigmented. 

The  organisms  capable  of  giving  rise  to  stones  are,  ac- 
cording to  Mignot,  the  bacillus  coli,  the  bacillus  typhosus, 
the  staphylococcus  pyogenes,  the  streptococcus  pyogenes, 
and  the  bacillus  subtilis.  More  important  than  the  indi- 
viduality of  the  organism  is  its  degree  of  attenuation. 

The  retention  or  stasis  of  bile  is  a  very  important  factor 
in  assisting  in  the  formation  of  gall-stones.  If  the  bile 
can  escape  freely  from  the  gall-bladder,  any  organisms 
injected  speedily  find  an  exit.  If,  however,  the  cystic 
duct  be  tied  or  a  foreign  body  placed  in  the  gall- 
bladder, the  organisms  find  a  foothold.  Miyake  and 
others,  in  their  experiments  with  the  colon  bacillus, 
failed  to  produce  the  formation  of  calculi  if  no  other 
factor  than  the  presence  of  microbes  was  in  evidence. 
Before  stones  could  be  produced  it  was  necessary  to 
impede  the  flow^  of  bile  through  the  cystic  duct.  Ehret 
and  Stolz  also  showed  that  a  diminution  of  the  motility  of 
the  gall-bladder,  or  anything  tending  to  retard  the  dis- 


44  Varieties  of   Gall-stones 

charge  of  bile,  favoured  the  growth  of  organisms  in  the 
gall-bladder.  Mignot,  in  a  series  of  experiments,  intro- 
duced foreign  bodies  impregnated  with  the  bacteria  whose 
action  was  to  be  tested  into  the  gall-bladder,  and  left 
them  there.  Gall-stones  were  found  to  have  fonned 
around  them  in  the  course  of  a  few  months.  In  another 
series  the  foreign  bodies  were  removed  at  the  end  of  four 
weeks  by  operation.  In  these,  also,  calculi  were  found  at 
the  end  of  four  and  five  months.  The  stones  formed  in 
both  series  were  comparable,  ' '  chemically,  physically,  and 
bacteriologically, ' '  with  those  found  in  man. 

Foreign  Bodies. — The  influence  of  foreign  bodies  in 
the  formation  of  gall-stones  was  first  recognised  in  man 
by  Romans.  In  a  patient  upon  whom  cholecystotomy 
had  been  performed  seventeen  months  before  a  second 
operation  became  necessary  on  account  of  a  return  of  symp- 
toms. Seven  stones  were  found,  and  five  of  these  had 
formed  around  silk  ligatures.  Similar  instances  have 
been  met  with  in  the  practice  of  other  surgeons.  Jacques 
Meyer,  experimenting  upon  dogs,  introduced  small  sterile 
ivory  balls  into  the  gall-bladder.  At  the  end  of  a  year 
a  small  amount  of  sediment  was  noticed  in  the  gall-blad- 
der, but  no  stone.  Even  when  hollow  balls  w^ere  used 
there  was  no  deposit  on  the  inner  side  of  the  globes.  Mig- 
not combined  the  introduction  of  sterile  foreign  bodies 
with  the  injection  of  attenuated  organisms.  The  injections 
were  made  first,  and  after  a  time  the  sterile  bodies  were 
introduced.  After  two  months  they  were  found  covered 
with  a  deposit  of  cholesterin.  In  a  series  of  19  animals 
the  foreign  body,  coated  with  cholesterin,  w^as  removed 
and  the  gall-bladder  closed.     At  the  end  of  six  months, 


Fig.  14. — Gall-stones  crystallized  around  sutures  (Homans,  in  "Annals 

of  Surgery"). 


Foreign   Bodies  45 

in  7  out  of  19  of  the  animals,  fine  stratified  cholesterin 
stones  were  found. 

Italia  (Riforma  Medica,  1901),  after  a  series  of  experi- 
ments with  various  organisms,  stated  his  results  in  the 
following  manner : 

1.  The  bacillus  coli  and  the  bacillus  typhosus  are  the 

specific  organisms  concerned  in  the  formation  of 
cholesterin  calculi. 

2.  The  streptococcus  pyogenes  and  the  staphylococcus 

pyogenes  aureus  are  rarely  the  causes  of  gall-stone 
formation.  When  they  are,  the  stone  consists 
solely  of  calcium  salts. 

3.  If  the  bacillus  coli  and   the   streptococcus   or  sta- 

phylococcus are  present,  the  stone  is  of  mixed  for- 
mation, consisting  of  cholesterin,  calcium  salts,  and 
bile  pigment. 

4.  The  bacillus  subtilis  grows  well  in  bile  but  does  not 

alter  it  in  any  way. 

The  following  conclusions  may  be  accepted : 

1.  The  chief  constituents  of  gall-stone,  cholesterin  and 

bilirubin  calcium,  are  produced  by  subacute  inflam- 
matory changes  in  the  mucous  membrane  of  the 
gall-bladder,  which  result  in  desquamation  of  epi- 
.thelium  and  in  increased  production  of  mucus. 

2 .  The  injection  of  a  virulent  culture  of  micro-organisms 

produces  an  acute  cholecystitis,  without  the  forma- 
tion of  gall-stones. 

3.  The  injection  of  attenuated  cultures  causes  no  change 

if  drainage  from  the  gall-bladder  is  free. 

4.  Retention  of  bile,  brought  about  by  the  introduction 

of  sterile  foreign  bodies,  does  not  cause  the  forma- 
tion of  stone. 

5.  If  retention  of   bile   be   caused  by  ligature  of   the 


46  Varieties  of   Gall-stones 

cystic  duct  or  by  the  introduction  of  foreign  bodies 
(which  cause  a  stasis  of  the  bile  adhering  to  them 
and  between  them),  and  an  attenuated  culture 
be  injected,  stone  formation  will  occur. 

6.  The  gall-bladder  is  the  chief  seat  of  the  formation  of 

gall-stones. 

7.  The  clumping  of  typhoid  bacilli  within  the  gall-blad- 

der may  possibly  furnish  an  explanation  of  the 
occurrence  of  cholelithiasis  after  typhoid  fever. 

All  these  researches  seem  to  assume  that  the  gall-bladder 
is  the  seat  of  the  formation  of  stones,  and  not  merely  the 
storehouse.  Doubtless  this  is  true  in  great  measure, 
but  the  question  as  to  the  formation  of  stones  and  as  to 
the  origin  of  bile  of  altered  quality  which  may  make  the 
stone-building  easier  within  the  intrahepatic  ducts,  is 
worthy  of  closer  investigation  than  it  has,  so  far,  received. 
In  the  smaller  bile-ducts  no  epithelial  lining  is  present, 
and  therefore  no  overproduction  of  cholesterin  is  possible. 

It  is  interesting  to  remember  that  gall-stones  are  found 
in  the  foetus,  and  that  the  intestinal  canal  of  the  foetus  is 
sterile.  The  stones  in  the  foetus  are,  however,  softer,  and 
seem  to  consist  of  bilirubin  calcium  chiefly. 

An  interesting  case,  bearing  upon  the  question  as  to  the 
time  needed  for  the  formation  of  gall-stones,  has  been 
recorded  by  Rokitisky  (Cent.  f.  Chir.,  1899,  p.  616). 
The  patient  was  a  woman,  twenty- three  years  of  age, 
who,  at  the  end  of  the  third  week,  in  an  attack  of  typhoid 
fever,  showed  all  the  signs  of  a  suppurative  cholecystitis. 
Six  days  later  the  gall-bladder  was  opened.  It  contained 
58  cholesterin  calculi.  On  section  the  stones  showed  a 
radiate  arrangement  and  seemed  to  be  of  recent  forma- 


Entrance  of  Micro-organisms  to  Bile  Passages    47 

tion.  The  bacillus  typhosus  was  found  in  the  centre  of  the 
calcuH  and  in  the  fluid  contained  in  the  gall-bladder.  There 
had  been  no  symptoms  of  any  kind  referable  to  the  gall- 
bladder or  to  the  stomach  before  the  onset  of  the  typhoid 
fever. 


ENTRANCE  OF  MICRO-ORGANISMS  TO  THE  BILE  PASSAGES. 

The  organisms  necessary  to  the  formation  of  gall-stones 
in  man  obtain  access  to  the  gall-bladder  and  bile  passages 
chiefly  in  two  ways : 

1.  Along  the  common  duct,  from  the  duodenum. 

2.  By  the  blood  current,  chiefly  from  the  portal  vein. 

1.  Along  the  Coiuiuoii  Duct. — The  first  route  is  prob- 
ably more  frequent.  The  fact  that  the  bacillus  coli  is  the 
most  common  bacterial  inhabitant  of  the  gall-bladder  and 
of  gall-stones  suggests  that  an  intestinal  origin  is  the  most 
likely,  for  this  organism  abounds  in  the  intestine,  though 
it  is  not,  as  a  rule,  present  in  large  numbers  in  the  duo- 
denum when  in  a  normal  condition.  The  bacteria  are 
normally  present,  as  has  been  mentioned,  in  the  lower 
part  of  the  common  duct ;  chiefly  in  the  ampulla  of  Vater 
in  animals;  and  in  man,  when  gall-stones  are  present,  the 
bacilli  are  more  numerous  in  the  common  duct  than  else- 
where. Sherrington  has  shown  (Journ.  Path,  and  Bact., 
1893)  that  no  germs  can  enter  the  bile-duct  from  the 
duodenum  so  long  as  the  bile  remains  normal  and  is  ex- 
pelled at  regular  intervals.  If,  however,  there  should  be 
any  obstruction  to  the  flow  of  bile,  and  therefore  stag- 
nation, there  is  an  instant  invasion  of  organisms. 

2.  The  Portal  Circulation.— The  view  that   the   most 


48  Varieties  of  Gall-stones 

frequent  route  of  infection  is  through  the  portal  vein 
has  recently  been  advocated  by  Lartigan  (New  York  Acad- 
emy of  Medicine,  1902,  quoted  by  Herter,  Med.  News, 
Sept.  26,  1903,  p.  592).  He  produced  inflammation  of  the 
intestine  of  dogs  by  means  of  various  irritants.  The  ani- 
mals were  then  fed  on  pathogenic  bacteria,  which  were 
soon  discovered  in  the  bile.  In  some  instances  the  cystic, 
in  others  the  common,  duct  was  ligatured  previous  to  the 
feeding  with  bacteria. 

On  the  other  hand,  Carmichael  (Joum.  Path,  and  Bact., 
vol.  8,  No.  3,  p.  276)  has  failed  to  find  any  evidence  of 
infection  after  the  injection  of  the  bacillus  typhosus,  bacil- 
lus coli,  and  streptococci  into  the  portal  circulation  of  rab- 
bits. He  considers  that  the  liver  destroys  the  micro-organ- 
isms that  reach  it  in  this  way,  and  that,  therefore,  the 
occurrence  of  biliary  infection  from  the  intestine  along 
this  path  is  highly  improbable. 

Adami,  writing  upon  this  subject,  says  that  we  may 
assume:  (i)  "  That  the  colon  bacilli  in  small  numbers  are 
in  the  healthy  individual  constantly  finding  their  way 
into  the  finer  branches  of  the  portal  circulation;  and  (2) 
that  one  of  the  functions  of  the  liver  is  to  arrest  the  fur- 
ther passage  of  these  bacilli  into  the  general  circulation 
and  to  destroy  them  through  the  agency  of  the  specific 
cells  of  the  organ.  Then  if  the  action  of  the  liver  cells 
has  been  disabled  by  the  toxic  products  of  the  bacteria 
these  may  reach  the  bile  and  spread  through  the  gall- 
bladder and  ducts." 

Blackstein  (Johns  Hopkins  Hospital  Bulletin,  vol.  2, 
p.  121,  1891 )  injected  bacteria  into  the  general  venous  sys- 
tem and  recovered  them  from  the  bile.     In  these  circum- 


Entrance  of  Micro-organisms  to  Bile  Passages    49 

stances  the  organisms  may  have  reached  the  hver  either  by 
the  portal  vein  or  by  the  cystic  artery.  Dr.  Welch,  in  a 
footnote  to  this  paper,  expresses  the  opinion  that  the  bile 
was  not  often  infective  in  these  experiments,  owing  to  the 
bactericidal  action  of  the  liver  cells.  The  infection  of  the 
bile  through  the  portal  vein,  however,  is  not  only  possible 
in  experimental  work  in  animals,  but  is  also  probable  in 
man,  especially  with  the  bacillus  typhosus  and  with  the 
bacillus  coli.  The  importance  of  inflammatory  or  ulcer- 
ative lesions  of  the  intestinal  tract,  in  opening  up  a  path 
for  the  entrance  of  organisms,  is  probably  of  great  impor- 
tance. During  recent  years  attention  has  been  called 
to  the  association  of  gall-stones  and  appendicitis.  Ochs- 
ner,  for  example,  has  found  that  a  little  more  than  35 
per  cent,  of  his  patients  operated  upon  for  gall-stones 
had  suffered  from  appendicitis  (Annals  of  Surgery,  vol. 
35,  p.  708).  I  have  on  several  occasions  simultaneously 
removed  the  appendix  and  performed  cholecystotomy 
or  cholecystectomy.  The  destructive  lesions  in  the  ap- 
pendix doubtless  allow  of  an  infection  of  the  blood  in  the 
portal  system. 

Gall-stones  when  once  formed  may  increase  in  size  in 
any  part  of  the  biliary  tract  in  which  they  may  chance 
to  lie.  Stones  formed  in  the  gall-bladder  which  have 
migrated  into  the  hepatic  or  cystic  or  common  ducts  may 
there  undergo  a  very  considerable  enlargement.  Stones 
may  be  found  in  the  common  duct  of  so  great  a  size  that 
it  is  impossible  for  them  to  have  passed  through  the  cystic 
duct.  Large  calculi  found  in  the  ducts  have,  therefore,  in 
all  cases  grown  after  their  passage  has  been  arrested. 

The  general  circumstances  determining  the  formation  of 
4 


50  Varieties  of   Gall-stones 

gall-stones  in  man  are  but  little  understood.  There  has 
been  a  considerable,  and,  so  far,  an  unprofitable,  dis- 
cussion as  to  the  part  played  in  the  causation  of  gall-stones 
by  certain  constitutional  conditions.  Herter,  after  a 
recapitulation  of  the  evidences  so  far  adduced,  writes: 

"  It  is  plain  from  what  has  been  said  that  there  is  at 
present  no  unequivocal  evidence  that  gall-stones  arise  from 
constitutional  derangements  unconnected  with  micro- 
organic  invasions  of  the  gall-bladder.  On  the  other  hand, 
it  is  certain  that  the  cholesterin  of  the  bile  can  be  consid- 
erably increased  by  local  irritants  unconnected  with  in- 
fection, and  it  is  likely  that  the  requisite  local  conditions 
for  such  increase  sometimes  arise  through  purely  meta- 
bolic disorders.  While  gall-stones  are  commonly  the  result 
of  local  infections,  we  should  carefully  guard  against  the 
conclusion  that  they  can  never  have  a  diathetic  origin. 
It  is  at  least  highly  probable  that  diathetic  conditions 
are  capable  of  so  altering  the  composition  of  the  bile  as  to 
favour  materially  the  production  of  calculi  in  the  presence 
of  suitable  local  bacterial  activities. ' ' 

And  again : 

' '  Derangements  in  general  metabolism  are  not  essen- 
tial factors  in  the  production  of  gall-stones.  This,  how- 
ever, is  no  evidence  that  disturbances  of  metabolism 
which  modify  the  composition  of  the  bile  may  not,  under 
certain  conditions,  play  an  important  part  in  bringing  on 
cholelithiasis. ' ' 

The  stagnation  of  bile,  the  importance  of  which,  as  a 
factor  in  causing  the  formation  of  calculi,  was  first  pointed 
out  bj^^-pmelius  in  1554,  has  been  attributed  to  a  great 
variety  of  causes.  Tight  lacing,  the  production  of  the 
so-called  ' '  corset-liver, ' '  sedentary  habits,  pregnancy,  tu- 


The  Ao^e  and  Sex  of   the  Patient 


51 


mours,  or  looseness  of  the  kidne}^  or  of  the  liver,  enterop- 
tosis,  growths  in  the  pancreas  and  stomach,  heart  disease, 
are  some  among  many  that  are  named.  Certain  alter- 
ations in  metabolism  are  also  credited  with  influence  — 
such,  for  example,  as  gout,  rheumatism,  diabetes,  and 
arteriosclerosis.  Frerichs  supposed  that  long  intervals 
between  meals  caused  an  infrequent  emptying  of  the 
gall-bladder  and  therefore  a  stasis  of  bile;  and  Charcot 
finds  an  atrophy  of  the  muscle  of  the  gall-bladder  in  the 
aged— a  fact  to  which  he  attributes  some  value. 

Ehret  has  found  gall-stones  in  four  generations,  and 
some  physicians  are  disposed  to  think  that  heredity 
must  be  considered  as  playing  a  part.  The  number  of 
suggestions  that  have  been  put  forward  are  remarkable 
for  their  number  and  for  their  worthlessness.  Much  has 
been  written,  but  little  is  known.  It  is  in  surgery  as  in 
finance — much  poverty  and  much  paper  may  coexist. 

The  age  and  sex  of  the  patient  have  doubtless  great 
influence  upon  the  formation  of  gall-stones.  The  following 
statistics  have  been  published  by  Schroder.  They  are 
based  upon  all  the  cases  examined  postmortem  by  v. 
Recklinghausen,  at  Strassburg,  in  the  years  1880-1887. 
The  patients  were  of  all  ages,  the  hospital  including  a 
children's  department: 


Age  of  Patients. 


Number  of 
Postmortems. 


0-20     

21-30     

31-40     

41-50 

51-60     . 

60  and  over 


82 
188 
209 
252 
161 
258 


Number  of 
Cases  with 
Gall-stones. 


2 

6 

24 
28 
16 
65 


Percentage  of 
Cases  Examined  in 
WHICH  Gall-stones 

WERE  Present. 


2.4 
3-2 

II-5 

II. I 

9.9 

25.2 


52  Varieties  of   Gall-stones 

Schroder  also  found  that  gall-stones  were  present  in  4.4 
per  cent,  of  the  male  bodies  examined  and  in  20.6  of  the 
female.  There  were  115  adult  women,  and  of  these  99 
had  certainly  borne  one  or  more  children,  and  in  5  the 
question  of  antecedent  pregnancy  was  doubtful ;  in  1 1  only 
was  there  undoubted  evidence  that  the  women  had  never 
been  pregnant. 

Fiedler  found  gall-stones  in  1 5  per  cent,  of  female  bodies 
examined  and  in  4  per  cent,  of  male  bodies ;  Roth  in  1 1 . 7 
per  cent,  and  4.7  per  cent. ;  Rother  in  9.9  per  cent,  and 
3.9  per  cent.,  respectively. 

Information  obtained  from  postmortem  experience  is, 
however,  almost  worthless.  We  learn  from  it  nothing 
whatever  as  to  the  length  of  time  a  patient  may  have 
suffered  from  gall-stones,  and  therefore  nothing  as  to  the 
period  of  their  incidence.  ]\Iore  reliable  information  can  be 
obtained  from  operation  records  which  give  the  age  of  the 
patient  at  the  time  of  the  operation,  and,  approximately, 
the  duration  of  symptoms. 

O.  Hartmann  (Zeit.  f.  klin.  Chir.,  vol.  68,  p.  230)  found 
the  average  of  his  male  patients,  who  earned  their  liv- 
ing by  manual  labour,  to  be  at  the  time  of  operation  forty 
years,  and  the  period  of  duration  of  symptoms  to  be  six 
years.  Of  the  leisure  class,  the  average  age  was  thirty- 
seven,  and  the  period  of  duration  of  symptoms  nine  years. 
In  women  of  the  working  class  the  average  age  was  thirty- 
five  and  one-half,  and  the  duration  of  symptoms  seven 
years ;  of  the  better  class  the  age  was  thirty-seven  and  the 
duration  of  symptoms  nine  years.  The  time  of  the  onset 
of  stone  was,  therefore,  in  all  classes  before  the  age  of 
thirty-five.     In   my  own   cases   the   average   age  of   the 


The  Age  and  Sex  'of   the   Patient  53 

patients  in  the  last  50  cases  was  forty- five,  and  the  dura- 
tion of  symptoms  five  and  one-half  years.  The  time  of 
onset,  therefore,  on  the  average  was  at  or  near  the  age  of 
forty.  At  the  Leeds  Infirmary,  including  the  cases,  male 
and  female,  of  all  the  staff,  the  average  age  of  the  last  50 
patients  was  forty-nine,  and  the  duration  of  symptoms 
six  and  one-quarter  years. 

There  may,  however,  be  an  increased  frequency  of  stone 
in  older  people  which  cannot  be  represented  in  any  list  of 
operations,  for  the  occurrence  of  cholelithiasis  in  the  aged 
may  be  devoid  of  symptoms.  There  are  observations  by 
Becquerel  and  others  which  go  to  show  that  cholesterin  is 
present  in  the  blood  in  larger  quantities  in  older  people 
than  in  those  in  the  prime  of  life.  Moreover,  the  in- 
creased production  of  cholesterin  by  the  epithelial  lining 
of  the  gall-bladder  may  well  be  a  specially  marked  attri- 
bute of  advanced  age,  occurring  as  a  natural  stage  in  the 
period  of  decadence.  It  is  then  not  due  to  any  such  con- 
dition as  the  ' '  lithogenous  catarrh ' '  already  described , 
but  rather  to  a  degenerative  condition,  comparable,  per- 
haps, with  atheroma.  When  stones  are  formed  under 
these  circumstances  their  presence  causes  no  symptoms, 
and  therefore  treatment,  either  by  the  physician  or  by  the 
surgeon,  is  never  sought.  The  fact,  however,  is  undoubted, 
that  the  age  of  patients  who  seek  relief  from  gall-stone  dis- 
ease by  operation  is  nearer  forty  than  fifty  years,  and  that 
in  them  the  onset  of  symptoms  occurs,  approximately, 
before  the  age  of  forty. 

The  occurrence  of  gall-stones  in  the  new-born  has  been 
observed  by  Lieutaud  and  Valleix.  The  latter  authority 
indeed  is  quoted  by  Naunyn  as  saying  that  ' '  concretions 


54  Varieties  of   Gall-stones 

are  somewhat  frequently  found  in  the  gall-bladders  of 
new-born  infants. ' ' 

An  interesting  paper  upon  ' '  Biliary  Calculi  in  Children, 
by  Dr.  G.  F.  Still,  is  published  in  the  Trans.  Path.  Soc., 
vol.  50,  p.  151.  The  following  details  are  extracted  there- 
from: Dr.  Still  finds  that,  including  three  cases  of  his 
own,  there  are  23  cases  recorded  in  which  gall-stones  were 
found,  either  in  the  faeces  during  life  or  at  an  autopsy. 
Of  the  23  cases  10  were  infants  who  were  stillborn  or 
died  within  a  few  weeks  of  birth ;  i  was  ' '  an  infant, ' '  4 
were  between  three  months  and  nine  months  of  age,  and  8 
were  children  from  three  to  fourteen  years  of  age.  Of 
the  10  cases  which  occurred  in  newborn  children,  7  are 
stated  to  have  been  jaundiced,  and  in  most  of  these  the 
jaundice  was  present  at  birth.  Abdominal  pain,  appar- 
ently of  the  nature  of  colic,  was  present  in  some  cases, 
but  not  in  all. 

In  one  case  (Bouisson)  some  narrowing  of  the  ductus 
choledochus  was  also  found ;  in  another  (Cuffer)  the  gall- 
bladder appeared  to  be  shrunken.  A  tendency  to  haemor- 
rhage was  also  associated  with  the  latter  case ;  haematuria 
and  hemorrhage  from  the  bowel  were  present  during 
life,  and  haemorrhage  into  the  psoas  muscle  was  found  after 
death.  The  jaundice  in  these  newborn  infants  was  very 
intense,  and  in  five  of  the  cases  was  shown,  postmortem, 
to  be  due  to  impaction  of  calculi  in  the  bile-ducts.  It  is 
evident,  therefore,  that  biliary  calculus  must  be  reckoned 
amongst  the  causes  of  icterus  neonatorum  of  a  severe  and 
persistent  variety,  which  in  some  cases,  at  least,  ends 
fatally. 

The  presence  of  gall-stones  in  later  infancy  and  in  child- 
hood has  rarely  been  associated  with  any  distinctive 
symptoms  during  life.     The  occurrence  of  jaundice  with 


The  Age  and  Sex  of   the  Patient  55 

colic  was  recorded  only  in  one  (Walker)  of  the  13  cases, 
while  in  another  (Case  3)  it  was  especially  stated  that  the 
child  had  screamed  much  and  drawn  up  its  legs  as  if  in 
pain.  In  the  remaining  11  cases  no  special  s^^mptom  of 
calculus  was  recorded. 

The  existence  of  pain  of  a  special  type  in  the  abdomen 
is  difficult  to  ascertain  in  infants  and  young  children. 
Colic  and  intestinal  disturbances  are  so  common  that  any 
special  observance  of  them  by  the  mother  is  not  likely. 
Pain,  therefore,  may  have  been  present  in  other  cases 
besides  the  two  in  which  it  was  mentioned.  The  passage 
of  calculi  along  the  bile-duct  is,  Dr.  Still  says,  ' '  certainly 
an  occasional  cause,  perhaps  a  more  common  one  than 
we  suspect,  of  colic  in  infants. 

Dr.  John  Thomson  and  Dr.  Still  are  both  of  opinion 
that  in  man}',  if  not  in  all  of  the  newborn  cases  the  cal- 
culi have  actually  been  formed  during  intra-uterine  life. 
The  condition  present  before  birth  which  favours  the  pro- 
duction of  biliary  concretions  is  probably  stagnation  of 
bile,  and  Dr.  Still  and  other  writers  have  commented  upon 
the  peculiarly  viscid  character  of  the  bile  in  infancy. 

These  theories  are  of  interest  as  bearing  upon  the  ques- 
tion of  the  formation  of  calculi  in  general.  In  the  adult 
and  in  animals,  as  shown  by  repeated  experiment,  the 
stones  are  always  microbic  in  orgin.  In  the  newborn 
the  alimentary  canal  is  sterile.  Investigation  as  to  the 
presence  of  organisms  in  the  bile  in  these  cases  of  gall- 
stones is  desirable. 

Dr.  Still's  three  cases  are  briefly  epitomised : 

Case  I. — C.  B.,  female,  aged  nine  months,  was  admitted 


56  Varieties  of   Gall-stones 

for  ^'omiting  and  wasting;  there  were  purpuric  patches, 
but  no  jaundice.  No  symptom  of  colic,  abdominal  pain, 
or  jaundice  was  noticed  during  the  time  the  child  was  in 
the  hospital.  At  the  autopsy  the  gall-bladder  was  filled 
with  golden-yellow  bile;  it  contained  11  small  calculi, 
angular,  dull,  black,  and  friable.  The  stones  were  sur- 
rounded by  inspissated  bile.  Three  calculi  were  impacted 
in  the  common  duct,  1.5  cm.  above  the  duodenal  opening. 
The  calculi  consisted  mainly  of  bile  pigment. 

Case  2. — M.  T.,  female,  aged  eight  months,  died  of 
acute  miliary  tuberculosis.  There  was  no  histor>^  of 
jaundice  or  abdominal  pain.  The  gall-bladder  contained 
some  golden-yellow  bile ;  near  its  neck  there  was  a  small 
area  about  3  mm.  in  diameter  where  the  mucous  membrane 
showed  superficial-  erosion,  and  adherent  to  this  was 
some  thick  mucus,  entangled  in  which  was  one  of  the 
minute  calculi  shown.  Only  three  of  these  minute  con- 
cretions were  present,  and  inasmuch  as  they  are  barely 
the  size  of  a  pin's  head,  they  are  hardly  worth  calling  cal- 
culi, but  are  of  importance  only  as  showing  the  tendency 
to  formation  of  calculus.  They  were  too  minute  to 
allow  of  any  satisfactory  chemical  examination. 

Case  3. — H.  C,  male,  aged  five  months,  died  from  ma- 
rasmus and  broncho-pneumonia.  The  gall-bladder  was 
moderately  full  of  rather  dark,  amber-coloured  bile,  and  in 
the  fundus  of  the  bladder  were  three  small  calculi,  the  larg- 
est being  about  the  size  of  a  millet  seed,  measuring  nearly 
3  mm.  by  2  mm.,  and  being  roughly  oval  in  shape,  with 
rounded  contour,  not  angular.  The  colour  was  a  dingy 
black,  the  consistence  was  very  hard,  but  they  were  friable 
under  considerable  pressure.  No  calculi  were  found  in 
the  liver  substance.  Examination  of  one  of  these  calculi 
showed  no  trace  of  cholesterin;  the  stone  seemed  to  be 
made  up  almost  entirely  of  bile  pigment  associated  appar- 
ently with  some  carbonate,  as  a  few  bubbles  of  gas  escaped 
on  adding  an  acid. 


CHAPTER  III. 

THE  GENERAL  PATHOLOGY  OF  GALL-STONE 
DISEASE. 

The  pathological  results  which  follow  upon  gall-stone 
disease  are  of  great  diversity. 

Cholecystitis. — In  the  gall-bladder  their  evidences  are 
most  commonly  and  most  deeply  imprinted.  In  the  early 
stages  there  may  be  very  slight  evidences  of  catarrh  of  the 
mucosa,  and  it  is  said  by  Janowski  that  in  this  stage  a 
hypertrophy  of  the  muscle  is  recognizable.  This,  however, 
must  be  only  in  the  earliest  stages  and  must  be  only  tran- 
sitory ;  it  is  not  to  be  discovered  in  any  of  the  specimens 
removed  by  me  in  the  performance  of  cholecystectomy. 
The  existence  of  specimens  of  hypertrophy  of  the  muscu- 
lar wall  of  the  gall-bladder  to  such  a  degree  as  to  cause 
fascination  is  authenticated.  The  condition  is  compar- 
able to  that  found  in  the  urinary  bladder.  Upstanding 
bands  of  hypertrophied  muscle  are  found,  and  between 
them  there  is  a  condition  of  sacculation.  I  can  find 
no  museum  specimens  showing  this  condition  in  man, 
though  a  specimen  from  an  ox  is  in  the  Royal  College  of 
Surgeons.  Schuppel  describes  a  specimen  in  his  possession, 
and  Gilbert  and  Fournier  make  mention  of  the  condition. 
In  one  specimen,  which  I  removed  by  cholecystectomy, 
the  wall  of  the  gall-bladder,  which  to  the  naked  eye  was 
but  little  altered,  showed  microscopically  a  decided  hyper- 


58       General   Pathology  of   Gall-stone  Disease 

trophy  of  the  muscular  layer.  This  condition  can,  how- 
ever, only  be  fugitive,  soon  giving  place  to  lesions  of  degen- 
eracy. 

Brockbank  has  met  with  two  cases  in  which  the  mucous 


Fig.  15. — Parts  of  the  liver  and  gall-bladder  of  an  ox.  Xo  cystic 
duct  can  be  traced ;  the  coats  of  the  gall-bladder  are  ^  inch  thick  and 
show  marked  sacculation,  such  as  that  seen  in  cases  of  long-continued 
distension  of  the  urinary  bladder  (Royal  College  of  Surgeons' Mviseum, 
No.  2804). 


membrane  of  the  gall-bladder  was  seen  with  the  naked 
eye  to  be  dotted  with  many  small  dark  specks  which 
could  be  easily  picked  out  with  a  sharp-pointed  instrument. 
Microscopical   preparations   of   these   specimens   showed 


Cholecystitis 


59 


that  the  black  specks  were  small  gall-stones  consisting  of 
beautiful  clear  crystals  of  cholesterin  of  the  ordinary- 
type  collected  together  in  large  numbers  and  covered  in 
places  with  biliary  pigment.      These    small    cholesterin 


Fig.  i6. — -A  gall-bladder  filled  with  gall-stones  which  was  removed 
by  operation,  during  which  the  muscvdar  coat  was  extensively  stripped 
from  the  mucous  membrane,  the  latter  being  tightly  stretched  over 
the  small  gall-stones  with  which  the  bladder  was  packed.  A  single 
large  stone  occupied  the  neck  of  the  gall-bladder,  the  inucous  mem- 
brane of  which  was  smooth,  opaque,  and  thickened. 

From  a  woman  aged  sixty-two.  The  operation  was  performed  in 
June,  1899.  Three  years  before  the  patient  had  an  attack  of  jaun- 
dice, with  pain  below  the  shoulder-blades;  this  was  followed  by  symp- 
toms of  chronic  dyspepsia,  and  in  October,  1898,  by  irregular  vomiting. 
The  patient  very  slowly  but  completely  recovered  from  the  dyspeptic 
symptoms  (University  College  Museum,  No.  1570). 


gall-stones  were  lying  in  spaces  in  the  mucous  membrane 
which  looked  like  retention  cysts.  Brockbank  calls 
these  calculi  ' '  intramucous  gall-stones. ' '  A  specimen 
(No.  1570)  in  the  museum  of  University  College  Hospital 
shows  a  gall-bladder  filled  with   gall-stones  which  was 


6o       General  Pathology  of  Gall-stone  Disease 

removed  by  operation,  during  which  the  muscular  coat 
was  extensively  stripped  from  the  mucous  membrane,  the 
latter  being  tightly  stretched  over  the  small  gall-stones 
with  which  the  bladder  was  packed.  A  similar  embedding 
of  stones  in  the  mucous  membrane  may  be  seen  in  the  com- 
mon, and  rarely  in  the  hepatic,  duct. 


Fig.  17.— Showing  ulceration  of  the  gall-bladder  and  thickening 
more  marked  at  the  pelvis  and  along  the  cystic  duct;  "hypertrophic 
sclerosis  of  the  gall-bladder." 


It  is  not  long  before  inflammatory  changes  are  recog- 
nisable in  all  the  coats  of  the  gall-bladder.  The  mucosa 
becomes  thickened,  mottled ;  in  parts  it  has  shed  its 
epithelium,  and  patches  of  ulceration  are  to  be  seen.  The 
muscular  layer  disappears  and  is  replaced  by  dense  bun- 
dles of  fibrous  tissue,  varying  greatly  in  thickness.     The 


Cholecystitis 


01 


Fig.  i8. — A  dilated  gall-bladder  with  thickened  walls,  containing 
five  calculi  embedded  in  its  mucous  membrane.  From  a  man  aged 
fifty-five  who  had  long  had  fixed  pain  in  the  right  hypochondritxm, 
bilious  vomiting,  and  occasional  jaundice;  after  two  years  a  tumour, 
increasing  in  size,  appeared  over  the  site  of  the  gall-bladder.  General 
anasarca  and  ascites  preceded  death  (King's  College  Hospital  Museum, 
No.  1022). 


62       General  Pathology  of   Gall-stone  Disease 

mucous  coat  at  the  first  shows  a  thickening  of  the  nattiral 
rugae  and  microscopically  an  infiltration  of  small  round 
cells ;  a  hypertrophy  of  the  glands  and  a  vascular  disten- 
sion are  observed.  There  is  an  abundant  desquamation  of 
epithelial  cells,  which,  according  to  Gilbert  and  Fournier, 
can  often  be  found  singly  or  in  masses  in  a  state  of  degen- 


FiG.  19. — A  gall-bladder  packed  with  small,  flat,  polygonal  stones, 
cemented  together  by  mucus;  there  were  no  symptoms  during  life 
(Charing  Cross  Hospital  Museum.  No.  13 17). 


eration  in  the  fluid  within  the  gall-bladder.  The  lesions 
in  the  mucosa  are  rapidly  progressive.  The  epithelium 
loses  its  normal  appearance,  the  cells  become  cubical  in 
shape,  and,  according  to  Gilbert,  a  transition  into  pave- 
ment epithelium  is  found.  The  rugae  now  begin  to  wither 
and  finally  disappear  completely,  the  Hning  of  the  gall- 


Cholecystitis 


^2> 


bladder  being  perfectly  smooth.  In  a  later  stage  a  divi- 
sion of  the  gall-bladder  wall  into  its  normal  layers  is  no 
longer  possible ;  all  that  can  be  seen  on  the  microscopical 


Fig.  20. — Showing  the  wall  of  the  gall-bladder  considerably,  but 
not  uniformly,  thickened,  to  |  inch  in  parts,  and  composed  of  dense 
fibrous  tissue,  with  opaque  whitish  areas  of  necrosis.  There  are 
adhesions  between  the  thin  margin  of  the  liver  and  the  gall-bladder, 
the  former  being  there  invaded  by  new  growth.  From  a  man  aged 
forty-four,  who  had  suffered  from  pain  in  the  epigastrium  off  and  on 
since  the  age  of  seventeen.  At  the  age  of  forty-four  he  was  jaundiced 
for  one  month  after  an  attack  of  pain ;  for  two  or  three  months  before 
operation  he  had  been  losing  flesh  and  failing  in  health.  The  gall- 
bladder and  the  adjacent  portion  of  the  liver  were  removed  by  an 
elastic  tourniquet.  The  patient  made  a  good  recovery  from  the 
operation,  but  death  took  place  three  months  afterwards,  owing  to 
secondary  growths  in  the  lower  part  of  the  abdomen  (Royal  College 
of  Surgeons'  Museum,   No.   2809  a). 


examination  is  a  fibrous  tissue,  but  little  vascular,  which 
is  sometimes  excessively  dense,  thick,  and  ligamentous. 
Such  cicatricial  tissue  soon  hastens  to  contract,  and  sclero- 


64       General  Pathology  of   Gall-stone  Disease 

sis  of  the  gall-bladder  is  the  final  result.  In  the  earliest 
stages  of  cholecystitis  there  is,  according  to  Langenbuch, 
some  oedema  of  the  wall  of  the  gall-bladder  and  an  in- 
creased activity  of  secretion  of  the  mucosa.  A  thin  mucous 
fluid  is  poured  out  into  the  gall-bladder  and  then  mixes 
with  the  bile      If  the  cvstic  duct  be  blocked,  the  bile,  after 


Fig.  2  I. — A  thickened  gall-bladder  closely  contracted  vipon  a  stone 
measuring  i^  inches  in  diameter  (Royal  College  of  Surgeons'  Museum, 
No.  2S19). 

a  time,  can  no  longer  be  discovered  in  the  fluid,  the  thin 
mucous  exudate  alone  being  present.  The  serous  coat  is 
turbid,  it  loses  its  polish,  and  contracts  adhesions  with 
the  surrounding  structures.  The  thickness  of  the  gall- 
bladder wall  is  sometimes  remarkable,  and  this  is  more  es- 
pecially the  case  in  the  pelvis  of  the  gall-bladder  and  at  the 
commencement  of  the  cystic  duct.     In  one  of  my  speci- 


i 


Cholecystitis  65 

mens  the  section  of  the  wall  is  here  i^  inches  in  thick- 
ness, and  the  tissue  is  dense,  white,  and  fibrous.  Before 
its  removal  it  was  thought  to  be  a  malignant  growth  of 
the  gall-bladder,  and  the  whole  of  the  gall-bladder  with 
the  adjacent  portion  of  the  liver  was  removed.  As  adhe- 
sions form  to  the  serous  coat  of  the  gall-bladder,  that  sur- 
face which  lies  in  contact  with  the  liver  becomes  more 
firmly  welded  to  it,  and  the  liver  substance  itself  becomes 
infiltrated  with  a  fibrous  deposit.  In  some  cases  a  fatty 
degeneration  of  the  liver  substance  is  found.  The  changes 
in  the  liver  substance  in  immediate  contact  with  the  gall- 
bladder are  more  marked  near  the  cystic  duct  than  near 
the  fundus.  In  some  cases  the  fibrous  gall-bladder  can  be 
separated  with  little  difficulty  from  the  liver,  at  or  near 
the  fundus.  The  separation  near  the  pelvis  is,  in  my 
experience,  always  a  matter  of  difficulty.  When  stones 
are  placed  irregularly  in  the  gall-bladder  the  contour  of 
the  viscus  may  be  greatly  altered.  The  gall-bladder  often 
shrinks  onto  the  stones  and  fits  accurately  into  all  the  ir- 
regularities of  their  surfaces.  One  of  the  forms  not  infre- 
quently^ assumed  by  the  gall-bladder  is  that  of  an  hour- 
glass. The  isthmus  which  separates  the  two  compartments 
may  be  nearer  the  fundus  or  nearer  the  cystic  duct,  most 
frequently  the  latter.  There  may  be  a  channel  connecting 
the  two  cavities  or  they  may  be  quite  separate;  if  so, 
the  contents  of  the  two  may  be  different — bile  may  be 
found  in  the  one  and  pus  in  another. 

The  gall-bladder  may  be  divided  into  two  compartments 
by  a  septum,  an  hour-glass  form  resulting.     Hotchkiss 
(Annals  of  Surgery,  vol.   19,  p.   200)  gives  the  following 
5 


66       General  Pathology  of  Gall-stone   Disease 

description  of  a  gall-bladder  that  was  found  to  be  in  a  con- 
dition of  gangrene : 

The  interior  of  the  bladder  presented  a  remarkable 
condition  in  that  it  was  almost  completely  divided  by  a 
thick  transverse  septum,  which  was  found  about  i^  inches 
from  the  end  of  the  fundus.  This  septum  was  complete 
except  for  a  small  aperture  about  ^  inch  in  diameter  near 
its  centre.  The  appearance  of  this  curious  partition  gave 
rise  to  the  question  as  to  whether  it  really  was  a  true 
septum  or  whether  the  apparent  cavity  of  the  fundus 
might  not  be  a  diverticulum.  With  a  view  to  determining 
this  point,  sections  were  made  through  the  septum  and 
through  the  thin  walls.  Mucous  membrane  was  found  ab- 
sent in  both  sections,  but  the  muscularis,  though  thinner 
than  elsewhere,  and  with  its  bundles  spread  apart,  was 
found  continuous  with  that  of  the  gall-bladder.  This 
proved  the  lower  gangrenous  end  of  the  tumor  to  be  the 
fundus  of  the  gall-bladder  and  not  a  diverticulum.  The 
walls  of  the  gall-bladder,  as  shown  in  both  sections,  but 
especially  the  walls  of  the  middle  portion,  were  found  infil- 
trated with  fibrin  and  pus.  The  amount  of  this  fibrinous 
exudate  was  so  great  as  easily  to  account  for  the  great 
thickness  of  the  walls  of  the  gall-bladder,  and  quite  suffi- 
cient to  determine  gangrene  of  the  fundus. 

Or  there  may  be  three  compartments,  or  even  more. 
Brockbank  and  others  have  described  a  multilocular  ap- 
pearance of  the  gall-bladder,  due  to  the  inward  projection 
and  fusion  of  numerous  septa.  By  this  means  the  gall- 
bladder is  divided  into  many  compartments,  in  each  one 
of  which  a  stone  may  be  found.  Such  incomplete  septa 
are  seen  quite  commonly  in  cases  of  chronic  cholecystitis. 
All  these  changes  in  ■  the  gall-bladder  are  inflammatory 


Cholecystitis 


^1 


in  origin.  The  appearances  described  therefore  ^'ary  ac- 
cording to  the  acuteness  or  the  chronicity  of  any  infection 
and  according  to  the  relative  duration  of  each  process, 
when  both  are  present.  In 
rare  instances  the  thickened 
and  inflamed  wall  of  the  gall- 
bladder may  show  an  abun- 
dant deposit  of  fat,  evenly 
distributed  throughout,  or 
placed  irregularly  in  larger  or 
smaller  masses.  In  a  speci- 
men (No.  1403)  in  Guy's  Hos- 
pital Museum  the  infiltration 
with  fat  measures  a  third  of 
an  inch  in  thickness,  being 
placed  between  the  serous 
and  submucous  coats.  A 
similar,  though  slighter,  con- 
dition was  found  in  one  of  my 
own  specimens  of  cholecystec- 
tomy. 

In  acute  inflammation  the 
catarrhal  condition  of  the 
mucosa  may  go  on  to  sup- 
puration. The  whole  of  the 
wall  is  swollen  and  thickened. 
Patches     of    ulceration     are 

numerous,  and  in  some  of  the  deeper  ulcers  a  stone 
may  be  seen  to  be  resting.  If  the  ulcer  deepens,  the 
stone  may  eventually  perforate  the  gall-bladder  wall, 
escaping  into   the    peritoneal    cavitv,    into    a    mass    of 


Fig.  22. — An  adipose  gall- 
bladder. The  infiltration  with 
fat  measures  a  third  of  an  inch 
in  thickness,  being  placed  be- 
tween the  serous  and  submu- 
cous coats.  From  a  man  aged 
sixty-sbc,  who  died  on  the  day 
after  admission  to  hospital. 
The  cellular  tissue  throughout 
the  body  was  loaded  with  fat; 
the  kidneys  were  granular,  the 
liver  cirrhotic  (Guy's  Hospital 
Museum,   No    1403). 


68       General   Pathology  of  Gall-stone  Disease 

adhesions,  or  into  the  liver  substance;  or  if  a  viscus 
be  adherent  to  the  outer  side,  an  internal  biliary  fis- 
tula may  form,  through  which  gall-stones  may  escape. 
In  the  more  acute  forms  of  inflammation  there  may  be 
patches  of  gangrene  in  the  wall  of  the  gall-bladder,  or 
the  whole  viscus  may  be  in  a  condition  of  phlegmonous 
ulceration.  Many  such  examples  are  quoted  in  the  chap- 
ter on  perforation  of  the  gall-bladder.  When  the  cystic 
duct  is  blocked,  and  even,  rarely,  when  it  is  patent,  and 
there  is  an  acute  virulent  infection  of  the  gall-bladder,  a 
purulent  collection  speedily  forms.  The  gall-bladder  is 
greatly  dilated,  its  walls  are  thickened,  deep  red  in  colour, 
sodden  with  inflammatory  exudate,  and  the  characteristic 
condition  of  empyema  of  the  gall-bladder  develops.  This 
may  lead  to  ulceration  and  perforation  of  the  gall-bladder, 
to  a  general  purulent  peritonitis,  or  the  whole  condition 
may  slowly  subside.  The  gall-bladder  lessens,  the  acute 
symptoms  disappear,  and  the  fluid  contents  are  either 
passed  into  the  ducts  or  in  part  absorbed.  Many 
weeks  after  such  an  acute  outburst  the  gall-bladder  may 
be  found  to  contain  pus,  though  it  is  shrunken  from  its 
former  size.  The  cystic  duct  is  still  found  blocked 
with  a  calculus  which  all  eft'orts  may  fail  to  dislodge. 

Hydrops  and  Empyema. — The  more  chronic  forms  of  in- 
flammation may  be  associated  with  distension  or  shrinkage 
of  the  gall-bladder  when  the  cystic  duct  is  blocked.  At 
the  first  a  h3^drops  of  the  gall-bladder  forms,  the  bile 
within  the  gall-bladder  being  absorbed.  In  hydrops 
the  physical  conditions  resemble  those  which  are  found 
in  empyema;  the  dift'erence  between  them  is  due  to  the 
dift'erent  desfrees  of  virulence  in  the  in^"ading  micro-organ- 


Fig.   23. — Cystoduodenal  fisUila:  Cholecystectomy.     A  deposit  of  fat 
is  seen  in  the  thickened  walls. 


i 


i 


Hydrops  and  Empyema 


69 


ism.  In  hydrops  the  wall  of  the  gall-bladder  may  be  grossly 
thickened  or  it  may  be  paper-thin  and  almost  translucent. 
There  is  both  an  atrophic  and  a  hypertrophic  sclerosis  of  the 
gall-bladder.  The  epithelium  is  lost  in  patches  and  has 
undergone  a  process 
of  flattening,  being 
transformed,  ac- 
cording to  Gilbert 
and  Fournier,  into 
the  semblance  of  a 
squamous  epithe- 
lium. It  has  indeed 
undergone  such  an 
alteration  as  to  be 
scarcely  or  not  at 
all  recognisable  as 
having  any  relation- 
ship with  that  norm- 
ally found.  A  dis- 
tended, easily  palp- 
able gall-bladder 
may  remain  un- 
altered for  many 
months,  even,  it 
may  be,  for  years. 
But  the  patient  who 

bears  it  is  in  a  condition  of  constant  peril,  for  rupture, 
ulceration,  or  acute  infection  may  at  any  moment  be 
aroused. 

The  following  examples  give  some  idea  of  the  enormous 
size  to  which  the  gall-bladder  may  attain : 


\ 


Fig.  24. — Stone  in  the  cystic  duct, 
drops  of  the  gall-bladder. 


70       General  Pathology  of  Gall-stone  Disease 


Lawson  Tait  (Lancet,  1889,  vol.  i,  p.  1294)  reports  a 
case  of  distended  gall-bladder  which  he  mistook  for  a 
parovarian  cyst.  The  patient  was  a  woman  forty  years 
of  age.  The  cyst  contained  eleven  pints  of  a  clear,  gluey 
fluid,  and  was  emptied  through  an  incision  made  between 

the  umbilicus  and  the 
pubes.  A  stone  was 
found  obstructing  the 
cystic  duct. 

Erdmann  (Mrch.  Ar- 
chiv,  Bd.  43)  relates  the 
case  of  a  man  twenty- 
four  years  of  age  who 
suffered  from  an  enor- 
mous abdominal  tumour 
from  which  60  to  80 
pounds  of  fluid  were  as- 
pirated. The  analysis  of 
the  fluid  shewed  it  to  be 
albuminous  and  to  con- 
tain a  trace  of  bile.  The 
tumour  was  regarded  as 
a  hydrops  of  the  gall- 
■n  ,.•       ,,  ^  ji  .  ^      bladder,  due  to  blockage 

riG.  25. — Vincents  case- oi   dilated  ° 

Rall-bladder.  of  the  cystic  duct. 


Vincent  (Rev.  de  Chir.,  1888,  viii,  753)  reports  the 
following  very  interesting  case : 

A  girl,  eight  and  one-half  years  old,  with  a  good  family 
history,  came  to  him  complaining  of  an  abdominal  tumour. 
Six  months  previously  her  mother  had  noticed  that  the 
child's  abdomen  was  larger,  but  the  patient  had  com- 
plained for  only  three  months  of  discomfort  from  the  size 
of  the  tumour  and  the  pain  in  it.  The  pain  had  never 
been  acute  and  was  rather  a  feeling  of  soreness  than  actual 


Fig.   26. — Gangrene  of  the  srall-bladder;   stone  in  the  cystic  duct. 


Hydrops  and  Empyema  71 

pain.  She  had  suffered  with  constipation  alternating 
with  diarrhoea.  Nothing  resembhng  gall-stones  had  ever 
been  seen  in  the  stools,  and  the  latter  had  not  been  ob- 
served to  be  clay-coloured.  The  child  was  ansemic, 
poorly  nourished,  and  slightly  jaundiced.  There  was  a 
continuous  elevation  of  temperature  of  ioo.5°-io2°  F. 
The  stools  were  hard  and  blackish  in  colour.  The  urine, 
300-400  c.c,  was  albuminous  and  contained  bile. 

Examination  of  the  abdomen  showed  it  to  be  fairly 
uniformly  distended,  but  rather  more  prominent  on 
the  right  side.  A  ridge  extended  from  the  right  hypo- 
chondriac to  the  left  iliac  region.  The  tumour  was  fluc- 
tuating, flat  on  percussion,  and  extended  two  finger- 
breadths  to  the  left  of  the  median  line  and  within  three 
fingerbreadths  of  the  symphysis. 

The  child  was  kept  under  observation  some  time  and 
after  aspirating  the  cyst,  when  160  c.c.  of  bile  were  ob- 
tained, a  cholecystotomy  was  finally  done.  Three  litres 
of  fluid  were  obtained. 

The  operation  and  the  autopsy  (for  the  child  died  ten 
days  after  operation)  showed  that  the  gall-bladder  was 
tremendously  dilated  and  hypertrophied,  its  walls  being 
^  mm.  in  thickness.  The  cystic  duct  was  obliterated, 
forming  a  part  of  the  cyst  wall.  The  hepatic  duct  was  in 
the  same  condition  and  likewise  helped  to  form  the  cyst ; 
the  openings  of  its  two  branches  admitted  the  thumb. 
Most  of  the  ductus  choledochus  also  took  part  in  the  form- 
ation of  the  cyst,  the  duct  being  represented  by  a  portion 
15-20  mm.  long,  its  opening  into  the  cyst  being  closed 
by  a  valve-like  projection  of  mucous  membrane.  While 
this  fold  of  mucosa  closed  the  duct  above,  a  probe  could 
be  passed  from  below  into  the  cyst.  The  pancreatic  duct 
was  ligated.     The  pancreas  and  spleen  were  enlarged. 

Vincent  considered  that  the  trouble  had  arisen  from 
the  presence  of  a  stone  or  lumbricoid  worm  in  the  common 
duct,  and  that  after  its  presence  had  caused  the  dilatation 


72       General  Pathology  of  Gall-stone  Disease 

of  the  gall-bladder  and  ducts  the  body  had  passed  into 
the  duodenum.  The  valve-like  fold  of  mucous  membrane 
in  the  common  duct  had  caused  the  continued  damming 
back  of  bile. 


Similar  enlargements  of  the  gall-bladder  are  seen  in 
empyema— thus  Berger  (Bull,  et  Mem.  Soc.  de  Paris,  vol. 
1 6,  p.  472)  operated  upon  a  pus-containing  gall-bladder 
which  filled  the  right  iliac  fossa  and  measured  16  cm.  by 
12  cm.,  and  Ternier,  from  a  "slightly  inflamed"  gall- 
bladder, removed  24  litres  of  fluid. 

If  the  hydrops  be  infected,  a  condition  of  empyema 
results;  if  it  be  not  infected,  then  the  gall-bladder  grad- 
ually dwindles  in  size  and  eventually  becomes  sclerosed. 
In  the  latter  case  the  cavity  of  the  gall-bladder  may  at 
the  last  be  so  small  as  to  be  difficult  of  recognition,  or  it 
may  certainly  be  entirely  obliterated.  In  one  example  of 
stricture  of  the  cystic  duct  the  gall-bladder  had  become 
reduced  to  a  mass  of  fibrous  tissue  less  than  an  inch  in 
length,  and  on  minute  examination  no  evidence  of  a 
cavity  could  be  discovered. 

Pericholecystitis. — The  extension  to  the  outer  surface 
of  the  gall-bladder  and  the  manifestations  thereon  are 
generally  proportioned  to  the  conditions  existing  within 
the  gall-bladder.  If  there  is  acute  inflammation  of  the 
gall-bladder,  a  local  acute  peritonitis  results  and  adhesions 
are  left  behind.  If  there  are  chronic  indurative  conditions, 
the  adhesions  are  numerous  and  intensely  difficult  to 
strip ;  they  are  formed  quietly  and  without  any  evidence 
of  acute  infection.  In  rare  cases  the  peritonitis  resulting 
from  an  acutely  inflamed  gall-bladder  may  be  puiiilent 


Fig.  27. — Empyema  of  the  gall-bladder.     From  a  patient  upon  whom 
the  author  successfully  performed  cholecystectomy. 


Pericholecystitis  'J2) 

when  no  rupture  of  the  gall-bladder  is  discoverable.     In- 
stances  are  recorded  by   Dilger,   Jacobs,  and   Billinger. 


Fig.  28. — A  gall-bladder  with  thickened  and  calcareous  walls 
which  contained  pus.  From  a  case  of  typhoid  fever,  in  the  fourth 
or  fifth  week  of  which  the  suppuration  is  believed  to  have  occurred 
(Royal  College  of  Surgeons'  Museum,   No.   2S06). 

When  the  gall-stones  have  become  quiescent  in  the  gall- 
bladder the   pericholecystitis    which   they    have   caused 


74       General  Pathology  of   Gall-stone  Disease 


may  be  the  one  condition  which  demands  surgical  inter- 
ference, by  reason  of  the  adhesions  crippling  the  stomach 
or  the  duodenum  and  thereby  causing  symptoms  of  pyloric 
obstruction. 

Calcification. — In  certain  cases  of  long-enduring  chole- 
cystitis a  calcification 
(it  is  sometimes  incor- 
rectly called  ossifica- 
tion) of  the  gall-blad- 
der may  be  found.  In 
the  fibrous  wall  of  the 
gall-bladder  smaller 
and  larger  plates  of 
T  JiH  calcification  are  recog- 

nisable, the  whole  ^•is- 
cus  seeming  to  be 
turned  into  a  twisted 
mass  of  bone.  In  the 
'^%;.:  ..  _  M  earliest    stages    small 

deposits  of  lime  salts 


Fig.  29. — A  calcareous  gall-bladder, 
the  coats  measuring  a  quarter  to  one- 
third  of  an  inch  in  thickness.  Its  in- 
terior was  filled  with  a  soft  solid  sub- 
stance containing  a  large  quantity  of 
cholesterin.  There  were  practically  no 
clinical  symptoms  (Royal  College  of 
Surgeons'  Museum,   Xo.   2823). 


are  found  only  in  the 
mucosa.  In  a  later 
stage  the  fibrous  wall 
of  the  gall-bladder  is 
encrusted  with  a  de- 
posit of  calcium  phos- 


phate. Pilliet,  who 
has  examined  many  specimens,  remarks  upon  the  striking 
similarity  that  the  process  of  calcification  of  the  gall-blad- 
der presents  to  that  of  atheroma  occurring  in  the  walls  of 
arteries.     Calcification  is  recognised  as  following  a  suppu- 


Formation  of  Diverticula  75 

rative  cholecystitis  in  the  great  majority  of  cases.  Com- 
plete calcification  of  the  gall-bladder  is  rare,  though 
examples  are  to  be  found  in  a  few  of  the  museums.  Riedel 
records  a  very  remarkable  case  in  which  the  calcification 
of  a  gall-bladder  was  of  such  density  as  to  require  the  use 
of  a  chisel  and  mallet  before  removal  could  be  effected. 

Formation  of  Diverticula.— One  of  the  most  remarkable 
of  the  later  results  of  gall-stone  irritation  is  the  formation 
of  diverticula  in  connexion  with  any  part  of  the  biliary 
passages.  The  mucous  membrane  is  worn  through  by 
ulceration,  the  stone  which  lies  in  contact  with  it  pushes 
the  outer  wall  of  the  gall-bladder  before  it,  and  finally 
comes  to  lie  in  a  separate  compartment,  which  is  shut  off 
completely  from  the  gall-bladder  in  some  instances,  but 
more  commonly  communicates  with  it  by  a  narrow  and 
often  tortuous  channel.  The  commonest  site  of  these  di- 
verticula is  in  the  pelvis  of  the  gall-bladder  or  in  the  cystic 
duct,  but  the  fundus,  or  indeed  any  part  of  the  gall-bladder, 
may  be  aft'ected.  A  very  remarkable  example  of  diver- 
ticulum occurring  from  the  fundus  is  recorded  by  Staub 
(Corresp.  f.  schw.  Aerzt.,  1896).  The  diverticulum  was 
opened  and  stones  removed  therefrom.  Behind  this  was 
felt  a  tumour  which  was  supposed  to  be  a  movable  kidney, 
but  which  proved  to  be  a  distended  gall-bladder.  In 
some  specimens  which  I  have  examined  there  was  a  con- 
dition seeminglv  of  diverticulum  at  the  outlet  of  the  gall- 
bladder which,  on  closer  examination,  proved  to  be  noth- 
ing more  than  the  lodgment  of  the  stone  in  the  first  part 
of  the  sigmoid  turn  of  the  cystic  duct.  Two  of  such 
specimens  I  have  removed  by  operation.     A  close  examin- 


']6       General  Pathology  of  Gall-stone  Disease 

ation  of  them  is  necessary  to  distinguish  them  from  those 
in  which  true  diverticula  have  been  formed. 

If  the  stone  ulcerate  more  deeply  into  the  wall  of  the 
gall-bladder  or  of  the  ducts,  a  protective  peritonitis  may 
occur  around  the  area  which  is  being  eroded  from  within. 
If,  in  such  circumstances,  the  destruction  of  the  gall-blad- 
der continues,  the  stone  may  finally  pass  through  the  wall 
and  come  to  lie  in  a  cavity  outside  the  gall-bladder.  Such 
cavities  are  often  described  as  "  secondary  gall-bladders. 
Very  good  examples  of  them  are  referred  to  in  the  article 
upon  perforation  of  the  gall-bladder. 

In  some  cases  the  gall-bladder  may  adhere  to  the  abdom- 
inal wall  and  stones  may  ulcerate  through ;  or  a  tumour, 
resembling  a  malignant  growth  in  the  muscles  of  the  ab- 
dominal wall,  may  be  formed.  Mordret  records  (Bull,  et 
Mem.  Soc.  de  Chir.,  vol.  29,  p.  1189)  a  case  where  a  tumour 
of  the  abdominal  wall,  not  adherent  to  the  skin,  was 
formed  in  this  way,  and  Michaux  refers  to  a  precisely 
similar  case  which  was  under  his  own  observation.  In 
the  former  case  cholecystotomy,  in  the  latter  cholecys- 
tectomy, w^as  performed. 

These  diverticula  may  be  found  also  burrowing  in  the 
liver  substance,  but  in  such  cases  it  is  hard  to  distin- 
guish them  from  an  actual  i)erf oration  of  the  gall-bladder 
and  the  formation  of  a  secondary  cavity  in  the  liver. 
Diverticula,  which  form  from  the  cystic  duct,  may  contain 
stones  of  large  size,  stones  which,  by  their  x^ressure, 
may  have  produced  obstruction  of  the  portal  vein,  of  the 
common  duct,  or  of  the  duodenum.  Many  examples  of 
mistaken  diagnosis,  resulting  from  this  condition,  are 
quoted  in  this  book.     If  the  portal  vein  is  obstructed, 


Formation  of  Diverticula  ']'] 

there  may  be  thrombosis,  and  ascites  will  result,  which, 
if  pressure  also  is  exerted  upon  the  common  duct,  will 
be  associated  with  jaundice.  .V  diagnosis  of  malignant 
disease  will  then  be  made,  as  recorded  by  McArthur,  Barrs, 
and  others.  If  pressure  be  made  upon  the  duodenum,  the 
signs  and  symptoms  of  pyloric  stenosis  will  be  manifest, 
and  an  operation  for  that  condition  will  be  undertaken. 
Examples  of  this  are  related  by  Alikulicz  and  Maclagan. 
In  one  of  his  cases  Mikulicz  performed  gastro-enteros- 
tomy,  and  only  six  months  later,  on  performing  chole- 
cystotomy,  discovered  the  cause  of  the  duodenal  obstruc- 
tion. In  another,  a  patient  aged  twenty-nine  had 
suffered  for  six  months  from  great  dilatation  of  the 
stomach  and  excessive  wasting.  Stenosis  of  the  pylorus 
from  simple  ulcer  was  diagnosed  and  an  operation  under- 
taken. After  opening  the  stomach  Mikulicz  found,  at 
the  base  of  the  pyloric  ulcer,  a  gall-stone  ' '  larger  than  a 
thumb  joint. ' ' 

Diverticula  are  also,  though  less  frequently,  found  in 
connexion  with  the  common  duct.  They  spring  almost 
invariably  from  the  upper  part  of  the  duct  and  do  not 
necessarily  cause  any  impediment  to  the  onward  flow 
of  bile ;  jaundice,  therefore,  may  be  absent. 

A  case  in  which  a  diverticulum  hsid  formed  from  the 
pancreatic  portion  of  the  duct  is  recorded  by  Thienhaus 
(Annals  of  Surgery,  vol.  36,  p.  927).  The  description  of 
the  operation  upon  this  case  is  reproduced  in  the  chapter 
dealing  with  operations  upon  the  common  duct. 

In  contradistinction  to  all  the  foregoing  there  are 
changes  in  the  wall  of  the  gall-bladder  and  of  the  ducts, 
especially  in  the  former,  which  lead,  not  to  thickening, 


78       General  Pathology  of   Gall-stone  Disease 

but   to  atrophy  of  the  walls.       In  some  instances   the 
gall-bladder,    "as  thin  as  paper,"  fits   closely  on  to  a 


Fig.  30. — Shewing  dilatation  of  the  gall-bladder  and  biliary 
ducts.  In  the  hepatic  ducts  are  several  large  brown  calculi;  a  small 
one  of  the  same  kind  lies  in  the  cystic  duct,  and  several  in  the  common 
duct,  but  there  are  none  in  the  gall-bladder  (Royal  College  of  Sur- 
geons'  Museum,    No.    2825). 

number  of  impacted  stones;  in  others,  exemplified  in  one 
of  my  cases  of  cholecystectomy,  there  may  be  a  small 
stone  impacted  in   the  cystic  duct  and  the  gall-bladder 


Changes  Seen   in   the   Common   Duct  79 

may  contain  only  a  few  drams  of  a  thin  and  watery 
fluid. 

When  a  great  part  of  the  wall  of  the  gall-bladder  seems 
healthy,  there  may  be  local  thickening  and  puckering  at 
the  site  of  an  old  ulcer.  These  scars  are  commonly  seen 
in  cases  of  old-standing  cholecystitis,  and  may  be  single 
or  multiple.  If  the  cholecystitis  has  been  acute,  or 
has  been  chronic,  adhesions  on  the  outer  surface  of  the 
gall-bladder  will  almost  certainly  be  seen.  When  the 
inflammation  is  of  recent  date,  the  adhesions  are  thin, 
filmy,  and  easily  detached;  w^hen  the  disease  is  of  old 
standing  the  adhesions  are  so  complex  that  half  an  hour 
may  be  spent  in  detaching  them  before  the  landmarks 
can  be  recognised.  The  gall-bladder  then  is  often  shrunken 
and  may  be  contracted  and  withered  almost  beyond  recog- 
nition. Such  adhesions,  the  result  of  a  pericholecystitis, 
may  aftect  all  the  adjacent  structures,  the  liver,  colon, 
duodenum,  and  stomach  being  all  gathered  up  into  a  mass 
of  the  densest  complexity. 

When  ulceration  extends  deeply  into  the  wall  of  the  gall- 
bladder the  peritonitis  which  results  upon  the  outer  sur- 
face may  result  in  the  adhesion  of  the  stomach,  the  duode- 
num, the  colon,  or  any  part  of  the  intestine.  If,  then, 
a  perforation  of  the  gall-bladder  occurs,  an  opening  is 
made  into  these  hollow  viscera  and  a  fistula  results. 

Changes  Seen  in  the  Common  Duct. — When  gall-stones 
are  for  any  length  of  time  fixed  in  the  common  duct  they 
give  rise  to  a  great  variety  of  altered  conditions.  The 
absolute  fixity  of  a  stone  is  rare.  As  has  been  shewn  by 
Fenger,  the  stone  soon  comes  to  act  as  a  "ball  valve." 
The  duct  behind  the  stone  becomes  dilated,  and  within 


So       General  Pathology  of   Gall-stone  Disease 

this  larger  duct  the  stone  is  free  to  move.  The  dilatation 
of  the  duct  is  chiefl}''  due  to  two  factors:  first,  inflam- 
mation, softening  the  duct  wall  and  causing  it  to  yield ; 
and  second,  the  pressure  of  the  bile.     The  secretion  pres- 


FiG.  31. — Chronic  cholecystitis  (calculous  disease).  The  gall- 
bladder is  represented  by  a  mass  of  tough  inflammatory  tissue,  sur- 
rounding a  small  cavity  in  which  lay  a  number  of  small  gall-stones. 
The  common  bile-duct  (laid  open)  is  much  dilated.  In  it  lay  three 
large  oval  stones;  two  removed  during  life  by  operation  through  the 
opening  seen  in  its  anterior  wall,  the  remaining  stone,  which  blocked 
the  duodenal  end  of  the  duct,  being  found  in  the  wound  at  the  autopsy. 
The  bile-ducts  and  the  liver  were  greatly  dilated,  and  the  liver  was 
deeply  jaundiced.  From  a  woman  aged  sixty.  At  the  operation 
much  difficulty  was  experienced  from  matting  of  the  tissues  around 
the  bile-ducts  in  the  hilum  of  the  liver  (Charing  Cross  Hospital  Museum, 
No.   1305). 

sure  of  the  bile  has  been  shewn  by  Noel  Paton  and  Bal- 
four  to  be  no  more  than  24  mm.  of  mercur}^;  l'>ut  this 
low  pressure  acting  constantly  upon  the  wall  of  a  weak- 
ened duct  is  amiple  to  produce  a  high  degree  of  dilatation. 
The  distension  of  the  common  duct  is  sometimes  remark- 


Changes  Seen   in  the   Common   Duct 


Fig.  32. — -Dilatation  of  the  common  bile-duct;  cholecystotomy; 
drainage.  On  the  under  surface  of  the  liver  is  a  thick-walled  cyst 
about  six  inches  in  diameter  the  interior  of  which  is  smooth  and 
presents  three  openings,  communicating  respectively  with  the  dilated 
hepatic  and  cystic  ducts  and  with  the  distal  portion  of  the  common 
duct.  The  last  f  inch  of  the  common  duct  is  of  less  than  normal 
calibre,  and  shews  a  valvular  fold  so  far  obstructing  its  lumen  that 
after  death  fluid  could  not  be  forced  from  the  cyst  through  the  biliary 
papilla.  From  a  Woman  aged  twenty-one,  who  for  two  and  one-half 
years  suffered  from  persistent  jaundice  the  onset  of  which  was  not 
preceded  by  pain.  A  tumour  in  the  hepatic  region  extending  to 
the  level  of  the  umbilicus  was  twice  aspirated,  three  and  a  half  pints 
being  removed  on  each  occasion.  Immediately  after  the  second 
aspiration  the  gall-bladder  was  laid  open  and  stitched  to  the  abdom- 
inal wall.  Death  took  place  two  days  later.  No  calculus  was  found 
(Guy's  Hospital  Mviseum,   No.    14 19). 


82       General  Pathology  of  Gall-stone  Disease 

able.  Terrier  records  three  cases  in  which  the  common 
duct  was  dilated  to  such  a  size  that  a  palpable  tumour 
was  observed ;  in  one  a  diagnosis  of  pancreatic  cyst  was 
made;  in  another  a  diagnosis  of  distended  gall-bladdcr, 
and  in  a  third  a  diagnosis  of  hydatid  cyst  of  the  liver. 
Several  instances  are  recorded  where  the  last  mistake  has 
been  made.  In  cases  recorded  by  Swain  and  Mayo  Rob- 
son  the  common  duct  has  been  dilated  to  a  degree  permit- 
ting its  anastomosis  with  the  small  intestine. 

Edgeworth  (Lancet,  1895,  i,  1180)  reports  the  following 
instance  of  dilatation  of  the  common  duct : 

The  patient,  a  girl  of  four  and  one-half  years,  had  been 
ciuite  well  until  six  months  of  age,  when  she  became  jaun- 
diced. This  lasted  two  or  three  weeks.  Since  that  time 
she  had  slight  recurrent  attacks  of  jaundice  every  six 
months  or  so.  Otherwise  she  had  been  w^ell  and  devel- 
oped normally,  .\bout  one  year  before  admission,  how- 
ever, when  three  and  one-half  years  old,  ' '  the  child's 
stomach  began  to  grow  big, ' '  and  this  enlargement  slowly 
increased,  though  none  the  less  the  girl  appeared  to  be  in 
good  health  until  about  four  weeks  before,  when  she 
became  thinner  in  body  and  face.  On  examination,  the 
patient  was  found  to  be  well  grown  for  her  age  and  moder- 
ately well  nourished.  There  was  a  slightly  yellow  tint  to 
the  conjunctivae  and  skin.  The  urine  contained  a  small 
amount  of  bile  pigments  and  no  albumin.  The  stools 
were  bile-stained.  The  liver  was  enlarged,  the  upper 
limit  of  dulness  extending  to  the  upper  border  of  the 
fourth  rib  in  the  nipple  line,  and  its  lower  edge  in  the  epi- 
gastric notch  being  lower  than  normal.  The  surface  of 
the  liver  in  the  latter  situation  felt  smooth  and  firm.  Im- 
mediately beneath  the  abdominal  wall,  in  portions  of  the 
epigastric,   umbilical,   right  hypochondriac,   and  lumbar 


Changes  Seen  in  the  Common  Duct  8 


J 


regions,  an  intra-abdominal  tumour  was  found  measur- 
ing about  three  inches  in  transverse  and  three  and  one-half 
inches  in  longitudinal  diameter,  with  the  lower  edge  one 
inch  below  the  level  of  the  umbilicus.  The  tumour  was 
slightly  movable  laterally,  of  rounded  shape  and  smooth 
surface,  with  an  elastic  feel  like  a  tightly  distended  bladder. 
Fluctuation  was  doubtful.  The  tumour  was  dull  on  per- 
cussion and  the  dulness  was  continuous  with  the  liver 
above.  vSpleen  enlarged;  no  ascites.  It  was  considered 
to  be  a  distended  gall-bladder.  The  tumour  was  incised, 
tw^enty-nine  ounces  of  normal  bile  were  evacuated,  and 
a  drainage-tube  inserted.  The  child  died  in  one  week  and 
at  autopsy  the  gall-bladder  was  found  very  small  and  con- 
tained a  little  inspissated  bile.  The  cystic  duct  was  oblit- 
erated, a  fibrous  cord  representing  it.  The  lower  end 
of  the  common  duct  was  stenosed ;  its  lumen  admitted  a 
hair-pin.  The  middle  portion  of  the  common  duct  was 
so  distended  as  to  form  the  sac,  which  had  a  thick  wall 
consisting  of  layers  of  fibrous  tissue.  The  common  duct 
above  this  and  the  hepatic  duct  were  somewhat  dilated, 
as  were  also  the  biliary  ducts.  The  liver  was  enlarged  and 
was  in  a  state  of  biliary  cirrhosis.  The  cause  of  the  condi- 
tion was  not  clear,  but  he  thought  it  due  to  repeated 
attacks  of  catarrh  of  the  ducts. 

Barlach  (Deut.  med.  Woch.,  1876,  No.  31)  observed  a 
thick-walled  cyst  almost  as  large  as  a  child's  head  formed 
by  a  dilatation  of  the  common  duct.  The  cyst  was  adherent 
to  the  stomach  above  and  communicated  with  it  by  a 
perforation  6  cm.  long.  The  gall-bladder  formed  an  ap- 
]3endage  to  the  upper  part  of  the  cyst,  with  which  it  com- 
municated by  a  small  opening ;  the  hepatic  duct  opened 
into  the  cyst.  The  cyst  was  formed  by  the  upper  part  of 
the  common  duct,  the  lower  part  being  blocked  by  "  a 
fleshy  tumour." 

Frerichs  (Klinik  d.  Leberkrankheiten,  vol.  2,  p.  433) 
describes  a  specimen  in  the  museum  at  Breslau  removed 


84       General  Patholog^y  of   Gall-stone   Disease 

from  a  woman  who  died  as  a  result  of  obstruction  of  the 
common  duct.  The  cystic  and  upper  parts  of  the  duct 
were  dilated  to  form  a  cyst  eight  inches  long  and  five  inches 
wide. 

In  Guy's  Hospital  ^Museum  is  a  specimen  (No.  1429) 
shewing  a  papilliferous  cyst  of  the  common  bile-duct, 
the  cyst  communicating  by  several  perforations  with  the 
first  part  of  the  duodenum.  The  patient  was  a  boy  aged 
four,  the  right  half  of  whose  abdomen  was  occupied  by  a 
fluctuating  swelling  from  \\'hich  five  pints  of  greenish, 
purulent  fluid  were  withdrawn.  After  death,  eleven  days 
later,  the  cyst  was  found  to  conmiunicate  with  the  cystic, 
hepatic,  and  common  bile-ducts  and  with  the  fundus  of 
the  gall-bladder. 

The  fluid  contained  in  these  dilated  ducts  is  generally 
bile,  for  the  obstruction  is  almost  always  intermittent 
and  of  the  ' '  ball  valve ' '  type.  Rarely,  however,  when  the 
obstruction  is  impassable,  the  fluid  is  clear,  as  was  first 
shewn  by  Aloxon.  The  mimicry  of  a  gall-bladder  whose 
outlet  is  blocked  by  a  stone  in  the  cystic  duct  is  then 
complete.  Complete  block  of  the  cystic  duct  or  of  the 
common  duct  results  in  the  retention  behind  them  of  a 
clear  or  slightly  turbid  fluid  containing  mucus.  Be- 
hind an  incomplete  or  intermittent  block  bile  is  re- 
tained. 

The  interior  of  the  duct  may  not  seldom  shew  evidence 
of  ulceration,  which  may  lead  to  the  formation,  in  the  last 
stage,  of  diverticula  or  of  fistulse.  Fistula  between  the 
termination  of  the  common  duct  and  the  duodenum  is 
probably  a  very  common  condition.  ]\Iany  examples  are 
recorded  under  the  name  of  ' '  wide-mouthed  opening ' '  of 
the  common  duct.     In  Courvoisier's  records  ulcerative 


Chanofes  Seen   in  the   Common   Duct 


85 


perforation  into  the  duodenum  occurred  in  six  cases,  into 
the  general  peritoneal, cavity  in  eight  cases. 


Fig  33.  —  Papuliferous  cyst  of  the  cuininun  bile-duct,  the  cavity  of 
the  cyst  communicating  by  several  perforations  with  the  first  part  of 
the  duodenum.  The  patient,  a  boy  aged  four,  was  admitted  for  en- 
largement of  the  abdomen,  emaciation,  and  vomiting  of  seven  months' 
duration.  The  right  half  of  the  abdomen  was  occupied  by  a  fluctuating 
swelling  from  which  five  pints  of  greenish,  purulent  fluid  were  with- 
drawn. After  death,  eleven  days  later,  the  cyst  was  found  to  com- 
municate with  the  cystic,  hepatic,  and  common  bile-ducts  and  with  the 
fundus  of  the  gall-bladder  (Guy's  Hospital  Museum,  No.  1429). 

The  ulceration  in  its  healing  causes  a  stricture,  and 
the  points  of  narrowing,  like  the  points  of  ulceration, 
may  be  single  or  may  be  many. 


86       General   Pathology  of   Gall-stone  Disease 

A  pericholangitis,  a  peritonitis  surrounding  the  common 
duct  at  its  upper  end,  may  be  one  of  the  results  of  inflam- 
mation within  the  duct,  and  bv  its  means  so  great  a  nar- 
rowing of  the  calibre  may  be  produced  that  jaundice  may 
be  present  as  an  enduring  svmptom. 

Suppurative  Cholangitis. — When  infection  of  the  gall- 
bladder and  bile-ducts  occurs,  every  stage  of  inflamma- 
tion of  the  mmcosa,  from  the  slightest  form  of  catarrh  up 
to  the  most  extensive  suppuration,  may  be  witnessed. 
In  the  gall-bladder  the  conditions  already  described  are 
found.  In  the  comimon  and  hepatic  ducts,  cholangitis, 
ulceration,  perforation  with  the  formation  of  fistula, 
and  widespread  suppuration,  extending  upwards  to  the 
smallest  of  the  ducts  within  the  liver,  may  be  found. 
The  inflammation  may  at  times  resemble  that  found  in 
membranous  cholecystitis,  and  casts  of  the  duct  of  larger 
or  smaller  size  may  be  found.  Thudichum.  in  his  work  on 
gall-stones,  asserted  that  the  nucleus  of  many  of  the  stones 
found  in  the  gall-bladder  could  be  shewn  to  consist  of  a 
cast  of  the  finest  hepatic  ducts,  but  his  observation  has 
lacked  confirmation.  When  inflammation  and  obstruction 
coexist,  the  walls  of  the  common  and  hepatic  ducts  give 
way.  In  chronic  cases  a  marked  thickening  of  the  duct, 
due  to  a  deposit  of  fibrous  tissue,  is  found.  When  the 
duct  is  incised  for  the  removal  of  a  stone,  its  walls  are  seen 
to  be  thick,  tough,  and  yellowish  white  in  colour.  The 
duct  beyond  the  calculus,  between  the  stone  and  the  duo- 
denum, is  often  softened  and  dilated  also  so  as  readily  to 
allow  of  the  passage  of  the  forefinger.  When  the  inflam- 
mation is  virulent,  the  suppuration  extending  into  the 
liver  mav  give  rise  to  the  condition  which  Leonard  Rogers 


Suppurative  Cholangitis  87 

has  aptly  termed  ' '  biliary  abscess. ' '  There  is  a  general 
suppurative  cholangitis,  and  the  liver  has  been  likened  to 
a  sponge  whose  interstices  are  filled  with  pus.  By  enlarging 
and  causing  disintegration  of  the  intervening  liver  sub- 
stance a  large  hepatic  abscess  may  be  formed,  which  may 
reach  the  surface  of  the  liv^er  and  then  burrow  upwards  into 
the  chest,  downwards  into  the  abdomen,  or,  in  the  most 
happy  event,  reach  the  surface  of  the  body.  The  contents 
of  such  abscesses  are  not  uncommonly  tinged  with  bile, 
and  when  there  is  a  general  purulent  disintegration  of  the 
liver,  hepatic  cells  may  be  found  on  examination  of  the 
fluid.  The  oft'ending  organisms  formed  in  the  pus  are 
the  bacillus  coli,  most  frequently,  and  the  staphylococcus 
pyogenes  aureus  and  albus,  and  various  streptococci. 

Suppurative  cholangitis  in  the  majority  of  instances  is 
found  as  a  result  of  occlusion  of  the  common  duct  by  a 
stone  or  other  foreign  body,  a  hydatid  for  example,  as  in 
two  cases  under  my  care.  The  condition,  however,  may 
result  from  tvphoid  fever,  and  the  typhoid  bacillus  alone, 
or  in  a  mixed  infection,  is  then  found  in  the  pus. 

Another  organism  found,  either  with  or  without  the 
presence  of  stones,  is  the  pneumococcus.  This  has  been 
found  alone  or  in  company  with  the  bacillus  coli.  Do- 
menici,  in  experimenting  upon  animals,  injected  bacillus 
coli,  typhoid  bacilli,  and  pneumococci  into  the  gall-bladder 
and  into  the  bile-ducts.  When  injected  into  the  former 
the  results  were  always  negative ;  when  into  the  latter, 
the  results  were  always  positive,  acute  cholangitis  result- 
ing. In  some  instances,  when  the  bacillus  of  typhoid 
and  the  pneumococcus  were  injected,  endocarditis  also 
resulted. 


88        General  Pathology  of   Gall-stone  Disease 

In  several  records  and  in  museum  specimens  the  impor- 
tance of  a  secondary  infection  upon  an  old-standinj^  disease 
of  the  common  dutt  is  shewn.  In  cases  where  there  is 
gall-stone  disease  in  any  of  its  various  forms  the  onset 
of  enteric  fever  adds  a  serious  risk  to  the  patient's  condi- 
tion, and  may  be  the  determining  cause  in  an  acute  sup- 
puration in  any  part  or  in  the  whole  of  the  bile  piassages. 
Hepatic  abscesses  depending  uj)on  cholelithiasis  may,  as 
shewn  by  Naunyn,  be  formed  in  se\'eral  ways : 

1.  An  empyema  of  the  gall-bladder  may  burst  into  the 
liver. 

2.  Purulent  cholangitis  of  the  intrahepatic  bile-ducts 
leads  to  ulceration  of  the  mucous  membrane,  and  the 
ulcerative  process  sj)reads  from  the  duct  walls  to  the 
neighbouring  parenchyma  of  the  liver.  The  bile-ducts, 
around  which  the  suppuration  occurs,  are  often  filled  with 
inspissated  pus,  or,  more  frequently  still,  with  dark- 
coloured  pultaceous  deposits  of  bilirubin  calcium. 

3.  Necrosis  of  the  liver  cells  at  the  periphery  of  the 
lobule,  suppuration,  and  the  casting  off  of  the  necrosed 
tissue;  the  process  of  "  hepatitis  sequestrans.' ' 

4.  Hepatic  abscess  occurring  with  cholelithiasis  ma\' 
be  embolic. 

Pylephlebitis  may  be  set  up  by  the  pressure  of  a  stone 
in  the  common  or  cystic  ducts,  causing  thrombosis  in  the 
disorganization. 

The  suppurative  j^rocess  extending  from  the  li\'er  may 
give  rise  to  a  subphrenic  abscess,  to  pleurisy,  or  to  empy- 
ema. In  one  case,  related  by  Simmons  (Amer.  Journ. 
Med.  Sci.,  Oct.,  1877,  p.  463),  an  abscess  burrowed  upwards 
into  the  anterior  mediastinum,  and  finallv  burst  into  the 


Membranous  Cholecystitis  and  Cholangitis      89 

right  bronchus.  Two  cases  are  recorded  by  Vissering  and 
Colvee,  in  which  gall-stones  have  been  coughed  up  with 
pus  and  bile. 

Biliary  abscess  of  the  liver,  general  suppurative  cho- 
langitis, is  due  in  the  majority  of  instances  to  gall-stone 
obstruction  in  the  common  or  hepatic  ducts.  Leonard 
Rogers  found  gall-stones  in  eighteen  out  of  twenty  cases 
whose  records  he  studied.  In  the  seventy-four  cases 
collected  by  Courvoisier  gall-stones  were  the  cause,  di- 
rectly or  indirectly,  in  fifty-seven. 

Membranous  cholecystitis  and  cholangitis  are  rare 
sequelse  of  gall-stone  irritation.  But  few  cases  of  this 
disease  are  recorded;  in  some,  gall-stones  were  present; 
in  some,  gall-stones  had  been  passed,  but  could  not  be 
found  at  the  autopsy ;  and  in  others  no  gall-stones  were  at 
any  time  perceptible.  The  following  case  is  recorded  by 
Fenwick  (Brit.  Med.  Journ.,  vol.  i,  1898,  p.  1072) : 

The  patient,  a  male,  aged  twenty-nine,  had  nine  attacks 
of  biliary  colic  in  the  last  fourteen  months,  accompanied 
by  more  or  less  severe  jaundice.  During  the  first  two 
attacks  he  passed  on  each  occasion  a  fairly  large  facetted 
gall-stone.  The  fseces  had  not  been  examined  during  the 
later  illnesses,  but  from  his  severe  pain  and  symptoms, 
exactly  resembling  his  earlier  attacks,  he  feels  sure  that 
he  has  passed  a  stone  on  each  occasion.  Fourteen  da3^s 
ago  he  had  a  severe  colic,  necessitating  the  use  of  mor- 
phine, and  next  day  passed  a  large  "piece  of  flesh," 
which  was  examined  by  his  doctor,  who  described  it  as  an 
oblong  sac,  with  mioderately  thick  walls,  stained  green, 
about  two  inches  long  and  one  inch  broad,  resembling  the 
gall-bladder  in  shape.  Ten  days  later  he  was  again  seized 
with  severe  pain,  similar  to  that  experienced  in  all  the 


I 


90       General  Pathology  of   Gall-stone  Disease 

former  illnesses,  and  after  some  hours  of  agony  he  was  re- 
lieved and  next  day  passed  another  cast  which  I  examined. 
It  is  two  inches  long,  one  and  one-half  inches  in  breadth, 
its  walls  are  one-tenth  of  an  inch  thick,  it  is  a  closed  sac 
with  a  distinct  neck,  and  is  stained  bright  green  in  parts, 
especially  towards  the  neck.  When  laid  out.  it  appears 
to  resemble  a  gall-bladder.  The  accom^panying  fa:ces 
were  clay-colored,  and  had  been  so  for  a  long  period  of 
time.  There  was  no  microscopic  appearance  of  hydatid 
structure,  and  I  do  not  think  that  it  was  an  intestinal  cast. 
We  came  to  the  conclusion  that  both  these  casts  were 
derived  from  the  gall-bladder,  as  the  patient  had  suffered 
from  tvpical  biliary  colic  many  times  before  the  passage  of 
the  casts  exactly  similar  to  that  he  had  felt  before  he 
passed  the  gall-stones. 

It  does  not  seem  improbable  that  the  presence  of  the 
stones  has  set  up  a  chronic  inflammation  in  the  bladder, 
which  has  resulted  in  the  formation  of  a  false  membrane, 
which  has  itself  been  exjjelled  after  the  last  stone  had  been 
passed. 

In  one  case,  related  by  Malmsten,  the  gall-bladder  of  a 
patient  who  had  died  of  general  peritonitis  was  found  to 
contain  a  croupous  exudation. 

Rolleston  (Path.  Soc.  Trans.,  vol.  53,  p.  405)  records  a 
case  in  which  a  fibrinous  cast  of  the  gall-bladder  was  asso- 
ciated with  a  gall-stone.     The  following  is  his  account : 

The  patient,  a  woman,  aged  fifty-two,  who  had  never 
had  jaundice  or  biliary  colic  previously,  was  suddenly 
seized  with  pain  on  the  right  side  of  the  abdomen  and 
vomiting.  On  admission  to  St.  George's  Hospital  two 
weeks  later  a  tumour  of  stony  hardness  was  found  in  the 
right  iliac  fossa,  separated  from  the  liver  dulness  by  a  zone 
of  resonance.     Laparotomy  was  performed  by  'Mr.  AUing- 


Membranous   Cholecystitis  and  Cholangitis      91 

ham,  and  revealed  a  greatly  enlarged  gall-bladder,  united 
by  adhesions  to  adjacent  parts.  On  opening  the  gall- 
bladder a  single  calculus,  rather  larger  than  a  walnut, 
enclosed  in  a  membranous  sac,  was  removed.  This  mem- 
brane was  easily  detached  from  the  walls  of  the  gall-blad- 
der and  was  brown  in  colour  and  not  unlike  a  dysmenor- 
rhoeal  cast  of  the  uterus.  Its  walls  were  from  a  quarter 
to  one-sixth  of  an  inch  thick,  varying  in  different  parts. 

Microscopically,  the  walls  of  the  cast  were  composed  of 
fibrin  enclosing  bile  pigment  and  hexagonal  and  quadri- 
lateral crystals.  The  crystals  were  soluble,  without  effer- 
vescence in  dilute  nitric  acid,  but  not  in  acetic  acid.  On 
the  outer  layer  of  the  cast  there  were  a  number  of  small 
round  cells,  and  scattered  through  the  fibrinous  network 
there  were  a  few  nuclei.  There  was  no  trace  of  the  mucous 
membrane  of  the  gall-bladder  in  this  membranous  cast. 
No  niicro-organisms  could  be  seen  in  specially  stained 
specimens. 

In  the  present  case  the  fibrinous  structure  of  the  mem- 
brane is  quite  different  from  the  histological  appearance 
of  the  intestinal  casts  of  mucous  colitis,  and  the  process 
cannot  be  considered  to  be  comparable  to  that  of  mucous 
colitis.  Its  structure  suggests  a  comparison  to  acute 
membranous  inflammations  of  mucous  surfaces,  such  as 
have  been  found  to  be  due  to  pneumococcal  infection, 
■but  pneumococci  were  not  found  in  this  case. 


The  association  of  attacks  of  a  nature  precisely  similar 
to  that  in  which  a  gall-stone  is  passed,  with  the  passage  of 
membranous  casts  in  the  fasces,  was  first  observed  by 
Richard  Powell:  "On  Certain  Painful  Affections  of  the 
Intestinal  Canal"  (Medical  Transactions  of  the  R.  C.  P., 
vol.  6,  p.  106,  1820).  These  casts  w^ere  due  to  the  disease 
now  regarded  as  "membranous  colitis."     There  is  noth- 


92        General   Pathology  of   Gall-stone   Disease 

ing  in  Dr.  Powell's  account  to  suggest  that  any  part  of  the 
casts  came  from  the  gall-bladder  or  bile-ducts.  The  asso- 
ciation of  cholelithiasis  with  membranous  colitis  has 
since  been  observed  by  Mayo  Robson,  myself,  and  others. 
The  following  case  of  membranous  cholecystitis  was 
under  my  care : 

History. — Mrs.  A.,  aged  forty-three.  Seen  August  21, 
1902,  with  Dr.  Carlton  Oldfield.  The  patient  had  suf- 
fered all  her  life  "from  spasms."  Pain  was  felt  in  the 
right  hypochondrium,  shooting  thence  through  to  the  back 
and  all  over  the  abdomen;  it  was  attended  by  vomit- 
ing and  collapse.  There  has  never  been  any  jaundice. 
Seven  weeks  ago  a  tumour  was  noticed  on  the  right  side  of 
the  abdomen,  a  little  above  and  internal  to  the  anterior 
superior  spine.  Constipation  has  latterly  been  a  marked 
feature,  and  distinct  intermittent  intestinal  coiling  has 
been  seen,  the  caecum  rising  up  very  prominently  and 
loud  borborygmi  have  been  heard.  On  several  occasions 
an  abundance  of  thick,  blood-stained  mucus  or  unstained 
mucus  has  been  passed  in  the  motions.  The  tumour  is 
densely  hard,  irregular  in  outline,  very  slightly  mo\'able 
laterally  and  vertically  during  respiration ;  it  is  not  tender 
to  the  touch.  A  diagnosis  of  growth  of  the  ascending  colon 
was  made  and  laparotomy  advised. 

Operation. — The  abdomen  was  opened  on  August  28th. 
A  hard  tumour,  adherent  to  the  abdominal  wall  and  as- 
cending colon,  was  found.  On  first  examination  it  was 
thought  that  the  diagnosis  was  accurate,  but  a  gradual 
separation  of  adhesions  revealed  the  gall-bladder  lying 
buried  in  a  trough  made  by  the  colon  and  adherent  by 
strong  bands  to  the  colon  and  abdominal  wall.  The  caecum 
was  large  and  very  much  hypertrophied,  feeling  tough  and 
leathery.  There  was  very  dense  thickening  and  stiffening 
of  the  ascending  colon  at  the  part  where  lay  the  distended 


Stricture  of    Ducts  93 

gall-bladder.  The  much-thickened  gall-bladder  was  laid 
open  and  368  stones  were  removed.  The  gall-bladder 
was  then  seen  to  be  lined  with  a  thick,  membranous  coat- 
ing, which  peeled  off  the  mucous  membrane  very  readily. 
The  condition  was  one  of  membranous  cholecystitis.  The 
gall-bladder  was  therefore  removed  with  a  portion  of  the 
cystic  duct,  and  the  abdominal  wound  closed  without 
drainage.  The  patient  made  a  perfect  recovery  and  is 
now  in  good  health,  doing  her  ordinary  household  duties. 

Stricture  of  Ducts. — The  ulceration  caused  by  gall- 
stones in  the  hepatic  or  common  ducts  may,  in  the  healing 
which  ensues  upon  the  passage  of  the  stone,  give  rise  to  a 
stricture  of  the  duct.  Hoffmann  (Virch.  Archiv,  Bd.  39, 
p.  206)  found  a  stricture  which  involved  the  common  he- 
patic duct  for  I  cm.,  the  left  hepatic  duct  for  1.4  cm.,  and 
the  right  for  0.8  cm.  The  finest  bristle  could  not  be  passed 
through  it ;  the  walls  of  the  stricture  were  thick  and  cica- 
tricial. Merbach  (Schmidt's  Jahrb.,  141,  p.  107)  records  a 
somewhat  similar  example.  Moxon  found  a  stricture  of 
the  hepatic  duct  in  a  man  of  thirty-one  years  of  age  who 
had  suffered  from  cholelithiasis.  It  w^as  situated  about 
one  inch  above  the  point  of  junction  with  the  cystic  duct. 
The  walls  were  irregularly  thickened  and  fibrous.  No  gall- 
stone was  found  in  the  duct,  nor  any  ulceration.  Bris- 
towe  (Path.  Soc.  Trans.,  vol.  9)  and  Holmes  (vol.  10) 
relate  cases  of  stricture  of  the  hepatic  duct.  The  latter 
calls  attention  to  the  resemblance  of  the  appearances  to 
those  found  in  stricture  of  the  urethra. 

Stenosis  of  the  common  duct  may  be  produced  in  a  sim- 
ilar manner,  or  the  duct  may  be  compressed,  twisted, 
kinked,  or  otherwise  warped  by  the  action  of  adhesions 


94       General  Pathology  of  Gall-stone  Disease 

which  surround  it.  Cases  in  which  a  stricture  of  the 
common  duct,  dependent  on  gall-stone  ulceration,  has 
been  excised,  are  recorded  by  Kehr  and  Mayo. 

Haemorrhage. — Haemorrhage  from  the  gall-bladder  and 
bile-ducts,  as  the  result  of  calculous  disease,  is  sometimes 
seen,  and  may  be  a  symptom  of  dire  significance.  In  old- 
standing  jaundice  a  tendency  to  haemorrhage  is  one  of  the 
most  remarkable  clinical  features.  Operations  upon  these 
patients  is  attended  by  the  risk  of  continued  bleeding, 
which  may  end  fatally.  This  tendency  is  decidedly  more 
frequently  present  when  the  jaundice  is  dependent  upon 
pancreatic  disease,  as  was  first  shewn  by  Mayo  Robson. 
The  hemorrhage  from  the  vessels  of  the  abdominal  wall 
may,  in  such  circumstances,  be  so  profuse  and  so  long-con- 
tinued as  to  be  the  immediate  cause  of  death.  In  patients 
so  affected  there  may  be  large  haemorrhages  into  the  sub- 
peritoneal tissue,  or,  indeed,  into  any  part  of  the  body,  as 
the  result  of  the  most  trivial  injury.  When  pressure  is  ex- 
erted by  a  stone,  in  the  cystic  or  common  ducts,  upon  the 
portal  vein,  there  may  be  submucous  haemorrhages  in  any 
part  of  the  intestinal  canal,  and  the  bleeding  from  the  con- 
gested surface  into  the  bowel  may  be  profuse.  A  case  is 
related  by  Naunyn  of  a  woman,  aged  fifty,  who  had  suf- 
fered from  jaundice  for  six  months;  ascites  developed 
rapidly,  and  about  three  weeks  later  there  was  a  profuse 
haematemesis,  with  melaena,  and  coma  developed.  At  the 
autopsy  a  stone  in  the  cystic  duct  was  found  to  be  press- 
ing upon  the  portal  vein,  which  contained  a  clot.  The  mu- 
cous membrane  of  the  intestine  and  of  the  stomach  exhib- 
ited haemorrhagic  areas  but  was  nowhere  ulcerated. 

Quinquaud — quoted  by  Hoppe-Seyler  and  Schiippel — 


Haemorrhage 


95 


Fig.  34. — -Shewing  the  gall-bladder  and  bile-dticts  distended  by 
blood:  Cholecystotomy  There  was  a  laceration  two  and  one-half 
inches  long  in  the  anterior  wall  of  the  gall-bladder.  The  cystic  duct 
and  lower  part  of  the  common  bile-duct  are  slightly  dilated,  the  re- 
mainder of  the  latter  and  the  hepatic  ducts  enormously  so.  Below  are 
seen  the  clots  removed  from  the  gall-bladder  (measuring  two  and  one- 
half  inches  transversely)  and  the  hepatic  duct  (one  and  one- quarter 
inches).  From  a  woman,  aged  fifty-four,  who,  while  suffering  from 
jaundice  of  two  months'  duration,  was  suddenly  seized  with  acute  ab- 
dominal pain  and  collapse,  together  with  a  rapidly  increasing  tumour  of 
the  gall-bladder.  Much  blood  was  passed  per  rectum.  Laparotomy 
was  performed  five  days  after  the  onset  of  the  acute  symptoms  and 
almost  a  pint  of  blood-clot  was  removed  from  the  gall-bladder.  Death 
took  place  a  few  hours  later  (Guy's  Hospital  Museum,  No.   1389). 


96       General  Pathology  of   Gall-stone  Disease 

described  a  case  of  hccmorrhagic  cholangitis  in  which  so 
large  a  quantity  of  blood  was  poured  into  the  bile-ducts 
and  into  the  intestine  that  death  followed  from  ha3mor- 
rhage. 

The  following  case  is  recorded  by  W.  Arbuthnot  Lane 
(Clin.  Soc.  Trans.,  vol.  28,  p.  160) : 

The  patient,  a  female,  aged  fifty-four,  was  admitted  to 
St.  John's  Hospital,  Lewisham,  on  December  20,  1894. 
Two  months  previously  she  had  developed  jaundice,  which 
became  very  deep.  There  was  no  history  of  a  previous 
attack  or  of  any  pain  or  discomfort  in  the  region  of  the 
gall-bladder.  The  liver  was  enlarged  and  she  had  pain 
about  the  gall-bladder.  On  December  16,  owing  to  the 
taking  of  a  strong  purgative,  she  was  seized  with  profuse 
diarrhoea,  with  severe  straining.  During  a  severe  bearing- 
down  effort  she  suddenly  exclaimed  that  she  had  felt  a 
very  sharp  pain  in  the  region  of  the  gall-bladder,  as  if 
something  had  given  way.  A  surgeon  was  sent  for,  who 
found  a  rounded  tumour  in  the  position  of  the  gall-bladder. 
The  diarrhoea  continued  in  a  lesser  degree  and  the  motions 
consisted  chiefly  of  blood.  Next  day  the  tumour  was 
larger,  but  the  pain  was  not  so  intense.  On  December  2 1 
she  was  much  worse,  and  the  temperature  rose  to  100°. 
Mr.  Lane  was  called  in  consultation.  He  decided  on  oper- 
ation and  exposed  the  gall-bladder  by  an  incision  over  it. 
The  tumour  protruded  at  once  through  the  wound,  when  it 
was  found  to  be  firm  and  inelastic,  like  a  soft  growth.  It 
was  incised  and  three-quarters  of  a  pint  of  blood-clot 
turned  out.  The  cystic,  hepatic,  and  common  ducts  were 
also  enormously  distended  with  clot.  No  stone  could  be 
felt.     The  patient  died  the  same  night. 

Postmortem. — The  gall-bladder  was  distended  to  about 
twice  its  normal  size  and  was  filled  with  clotted  blood. 
The  common  duct  was  greatly  distended  and  was  com- 


Haemorrhage  97 

pletely  filled  with  firm  blood-clot,  which  extended  into 
the  main  hepatic  duct  and  into  the  branches  of  the  ducts 
within  the  liver. 

The  mucous  membrane  of  the  gall-bladder  was  lacerated 
for  a  distance  of  about  one  inch  and  a  half  in  the  anterior 
wall,  and  the  rent  extended  for  a  small  distance  into  the 
substance  of  the  liver.  In  the  absence  of  any  other  dis- 
covered cause,  it  appears  probable  that  this  laceration  of 
the  mucosa  was  the  source  of  the  haemorrhage.  No  gall- 
bladder stone  was  found  nor  any  other  cause  for  the  jaun- 
dice than  the  obstruction  of  the  ducts  by  the  blood-clot. 

It  is  possible  that  the  stone  which  produced  the  obstruc- 
tive jaundice  was  forced  into  the  bowel  by  the  pressure  of 
the  blood  behind  it,  and  that  it  escaped  unobserved  in 
the  evacuations  which  were  thrown  away  by  the  friends. 
(Guy's  Hospital  Museum,  Specimen,  No.  1389.) 

Many  cases  are  recorded  of  hemorrhage  from  the  stom- 
ach or  from  the  bowels  during  the  formation  of  fistulas  be- 
tween the  gall-bladder  and  the  alimentary  canal.  Fatal 
haemorrhage  from  the  biliary  passages  as  the  result  of 
cholelithiasis  is  recorded  by  several  writers,  Naunyn, 
Chiari,  and  others.  In  some  of  these  false  aneurysms 
of  the  hepatic  or  of  the  cystic  arteries  have  been  found  to 
have  ruptured.  The  following  case  is  recorded  by  Calm 
and  quoted  by  Naunyn : 

An  elderly  woman  had  long  suffered  from  epigastric 
pain  and  vomiting  after  food.  The  diagnosis  lay  between 
round  ulcer  of  the  stomach  or  duodenum  and  cholelithiasis. 
No  gall-stones  could  ever  be  found  in  the  stools.  Five 
weeks  before  her  death  there  occurred  a  copious  gastric  and 
intestinal  haemorrhage,  and  a  few  days  later  a  more  severe 
one,  with  the  passage  of  bright  red  blood  from  the  bowel. 
7 


98       General  Pathology  of  Gall-stone  Disease 

Then  followed  slight  jaundice,  without  discolouration  of 
the  stools,  and  this  repeatedly  recurred  in  a  transitory 
manner.  A  similar  haemorrhage  occurred  three  weeks 
before  death,  and  finally  a  rapidly  fatal  intestinal  haemor- 
rhage. At  the  postmortem  there  was  found  a  false 
aneurysm  of  the  right  hepatic  artery  "which  lay  in  con- 
tact with  that  part  of  the  hepatic  duct  which  was  over 
against  the  point  of  a  gall-stone  which  had  penetrated 
into  it  from  the  cystic  duct."  This  aneurysm  had  rup- 
tured into  the  hepatic  duct.  There  were,  in  addition, 
three  perforations  from  the  gall-bladder  into  the  duo- 
denum. 

Many  fatal  cases  of  hemorrhage  into  the  gall-bladder 
and  ducts  after  operation  are  recorded  by  Riedel,  Quenu, 
and  others. 

Schwartz  relates  (Bull,  et  Mem.  Soc.  de  Chir.,  vol.  29, 
p.  677)  the  case  of  a  man  of  forty-three  who  was  operated 
upon  in  April,  1901,  for  cholelithiasis.  The  gall-bladder 
contained  a  litre  of  bile.  The  common  duct  was  ex- 
plored w4th  a  negative  result.  The  head  of  the  pancreas 
was  found  increased  in  size  and  indurated.  Cholecystot- 
omy  was  performed.  A  biliary  fistula  persisted  until 
January,  1903,  when  he  became  jaundiced  and  died 
from  profuse  and  incoercible  haemorrhage  from  the 
fistula. 

Malignant  Disease. — One  of  the  most  serious  of  the  se- 
quelce  of  cholelithiasis  is  malignant  disease  of  the  gall- 
bladder or  of  the  ducts.  The  close  connexion  between  gall- 
stones and  malignant  disease  has  never  lacked  recognition, 
though  opinions  have  differed  as  to  which  is  the  cause  and 
which  the  effect.  Opinion  is  now  universally  in  favour  of 
the   view   that    it    is    the    irritation    of    the    gall-stones 


Malicrnant  Disease 


99 


that  determines  the  incidence 
was  first  supported  by  Klebs. 
Courvoisier  found  the  follow- 
ing results : 

Of  84  cases  of  primary  can- 
cer of  the  gall-bladder,  there 
were  72  in  which  stone  were 
found ;  in  two  others  stone  had 
been  passed  in  the  motions. 
In  the  remaining  10  no  men- 
tion of  stones  is  made ;  in 
four  of  these  there  were  cer- 
tain pathological  changes : 
scarring  of  the  duodenal  pa- 
pilla, stricture  thereof,  and 
dilatation  of  all  the  bile  pass- 
ages, which  indicated,  un- 
questionably, the  former 
presence  of  calculi. 

Janowski  quotes  Brodow- 
ski  as  having  examined  40 
cases  of  primary  cancer  and 
finding  gall-stones  in  all. 

Siegert  (Virchow's  Archiv, 
Bd.  132,  H.  2,  1893)  investi- 
gated cases  both  of  primary 
and  of  secondary  cancer.  In 
primary  cancer  gall-stones 
are  present  in  15  per  cent. 
Musser,  wTiting  in  1889,  had 
100  cases  of  primary  cancer  of 


of  cancer,  the  view  that 
In  his  record  of  cases 


Fig.  35. — Papillomata  of 
gall-bladder.  From  a  woman 
aged  fifty-nine  who  died  from 
phthisis.  Two  large  facetted 
calculi  and  some  fragments  of 
a  third  were  found  in  the  gall- 
bladder (Guy's  Hospital  Mus- 
eum, No.  1404). 


collected    the   notes    of 
the  gall-bladder,  verified 


Fig.  36. — Primary  columnar-celled  cancer  of  the  bile-ducts.  The 
common  bile-duct  shews,  at  its  junction  with  the  cystic  duct,  a  tight 
cancerous  stricture  which  involves  also  the  latter.  The  bile-ducts 
above  are  extremely  dilated  and  the  liver  deeply  jaundiced.  The 
gall-bladder  presents  a  deep-red  inflammatory  appearance  (following 
on  operation).  From  a  woman,  aged  forty-five,  who  experienced 
severe  epigastric  pain,  jaundice,  and  vomiting  about  two  months 
before  admission.  A  kimp  had  been  noticed  in  the  abdomen  for  five 
weeks  and  the  lower  edge  of  the  enlarged  liver  reached  nearly  to  the 
umbilicus.  The  liver  surface  was  irregular,  but  presented  no  nodules. 
The  gall-bladder  was  opened  and  thirty-two  stones  were  removed, 
some  embedded  in  solid  material  connected  with  the  wall;  seven 
more  were  extracted  from  a  pouch  at  the  exit  of  the  cystic  duct.  A 
hard  lump  was  felt  in  the  common  duct,  and  a  second  similar  lump 
in  the  cystic  duct.  The  opening  in  the  gall-bladder  was  sewn  to 
the  parietal  peritonetim  and  a  tube  inserted.  After  operation  there 
were  progressive  weakness,  increasing  jaundice,  and  slight  but  per- 
sistent pyrexia   (Charing  Cross  Hospital  Museum,   No.    1332). 


Malifrnant  Disease 


lOI 


postmortem.  Gall-stones  were  present  in  69.  Jay le,  in  30 
cases  collected  entirely  from  French  records,  found  that 
stones  were  present  in  23  cases. 


Fig.   37. — Carcinoma  of  gall-bladder,  with  gall-stones.      Secondary 
deposits  in  the  liver  (London  Hospital  Museum,  No.  212). 

Primary  carcinoma  of  the  bile-ducts  is  far  less  commonly 
seen  than  in  cancer  of  the  gall-bladder,  and  the  association 
between  gall-stones  and  growth  is  not  so  clearly  shewn  in 


I02     General  Pathology  of   Gall-stone  Disease 

postmortem  records.  A  specimen  of  primary  columnar- 
celled  carcinoma  of  the  bile-ducts  due  to  gall-stone  irrita- 
tion is  in  the  Museum  of  Charing  Cross  Hospital  (Xo.  1332). 
Rolleston,  writing  in  1896,  found  that  stones  were  present 
in  only  four  cases  out  of  11.  He  considers  that  calculi  are 
less  commonly  associated  with  cancer  of  the  bile-duct 
than  with  cancer  of  the  gall-bladder,  but  he  admits  the 
possibility  of- the  passage  of  gall-stones  after  the  develop- 
ment of  the  growth  and  before  the  death  of  the  patient. 
Courvoisier  gives  two  cases  of  cancer  of  the  common  duct 
due  to  the  irritation  of  stones. 

Ingelrans  found  that  in  cancer  of  the  hepatic  duct  the 
association  with  gall-stones  was  unusual. 

In  some  of  the  museum  examples  the  implantation  of 
the  malignant  change  upon  a  chronic  ulcer  of  the  gall-blad- 
der is  well  seen.  The  condition  is  exactly  similar  to  that 
of  "ulcus  carcinomatosum "  seen  in  chronic  ulcer  of  the 
stomach. 

An  examination  into  the  records  of  a  number  of  cases  of 
cancer  due  to  gall-stones  shews  that  in  many,  certainly  in 
a  majority,  jaundice  had  never  been  present.  The  symp- 
tom most  commonly  recorded  is  cramp  in  the  stomach, 
followed  by  sickness  and  vomiting.  The  symptoms,  that 
is  to  say,  are  in  the  greater  number  of  cases  those  due  to 
stone  contained  within  the  gall-bladder.  Though  gall- 
stones are  present  and  are  the  cause  of  the  malignant  dis- 
ease, they  may  never  have  been  suspected. 

In  very  rare  instances  malignant  disease  of  the  gall-blad- 
der may  occur  after  cholecystotomy.  The  following  case 
was  under  the  care  of  my  colleague,  ]\Ir.  Lawford  Knaggs, 
to  whom  I  am  greatly  indebted  for  the  notes : 


Maliornant  Disease  lo' 


fc. 


Sarah  D.,  aged  sixty-nine,  a  spare  old  woman,  who 
looked  and  expressed  herself  as  being  very  healthy,  was 
admitted  on  September  8,  1902.  She  had  never  had"  any 
trouble  with  her  digestion  or  her  bowels  except  some  slight 
diarrhoea  two  years  before.  Seven  weeks  before  admission 
she  felt  pain  in  the  right  hypochondrium  which  wore  her 
down  when  she  walked.  The  pain  gradually  mounted 
higher  till  it  was  felt  over  the  lower  ribs,  and  her  doctor 
discovered  a  tumour  in  the  right  loin. 

She  had  never  been  jaundiced  or  had  any  attack  of 
severe  abdominal  pain  and  she  had  lost  no  flesh.  She 
had  a  goitre  of  long  duration  which  caused  no  trouble. 

On  examination,  a  smooth,  rounded  swelling  was  found 
in  the  right  loin.  It  was  evidently  attached  to  the  liver  and 
was  regarded  as  a  distended  gall-bladder,  which,  from  its 
mobility,  was  free  from  adhesions.  A  tender  spot  was  al- 
wavs  to  be  found  on  pressure  at  a  point  midway  between 
the  umbilicus  and  the  tip  of  the  ninth  rib,  and  a  gall-stone 
impacted  in  the  cystic  duct  w^as  diagnosed. 

The  urine  was  normal. 

On  September  1 1  the  patient  was  anaesthetised  and  an 
incision  was  made  over  the  gall-bladder.  This,  much  elon- 
gated and  distended  to  the  size  of  a  fist,  was  drawn  out  of 
the  wound  and  a  quantity  of  foul-smelling  fluid  with  some 
pus  was  drawn  off  by  the  aspirator.  A  single  stone  was 
felt  in  the  cystic  duct  and  was  squeezed  back  into  the  gall- 
bladder and  removed.  It  was  about  the  size  of  a  nutmeg, 
oval,  and  not  facetted. 

The  gall-bladder  was  very  long  and  supple,  not  notice- 
ably thickened,  and  no  suspicion  of  anything  abnormal 
was  raised  by  the  examination  of  the  cystic  and  common 
ducts  which  was  made  in  the  routine  manner.  An  india- 
rubber  tube  was  now  fixed  in  the  gall-bladder,  which  was 
then  attached  to  the  aponeurosis,  but,  owing  to  its  length, 
a  portion  of  the  gall-bladder  wall  was  allowed  to  lie  above 
the  opening  and  between  the  lips  of  the  skin  incision.   From 


104     General  Pathology  of   Gall-stone  Disease 

this  circumstance  the  fistulous  opening  refused  to  close, 
but  the  amount  of  bile  that  came  from  it  steadily  dimin- 
ished and  became  so  trivial  that  it  proved  to  be  no  discom- 
fort to  the  patient.  Consequently,  no  thought  of  doing 
anything  to  close  it  was  entertained.  The  following  report 
of  the  fluid  removed  from  the  gall-bladder  was  made  by 
J.  A.  C.  Forsyth,  M.  B. : 

"  On  agar  there  was  an  active  growth  in  five  hours.  At 
the  end  of  three  da^^s  culture  examined.  Foul  odour 
noticed  on  withdrawing  plug  from  tube.  Film  prepara- 
tions show  bacillus  coli  communis  in  pure  culture.  " 

The  patient  left  the  hospital  on  October  19,  1902.  She 
was  seen  from  time  to  time  as  an  out-patient  and,  except 
for  the  fistulous  opening  discharging  a  ver\^  little  bile,  she 
was  quite  well. 

About  the  end  of  1903  she  came  complaining  of  pain  in 
the  right  hypochondrium.  She  stated  that  the  fistula  had 
closed  and  that  the  pain  began  as  soon  as  it  ceased  to  dis- 
charge. Some  thickening  under  the  skin  around  the  cica- 
trix of  the  fistula  was  to  be  felt,  but  this  was  attributed  to 
the  redundant  portion  of  the  gall-bladder  which  had  been 
allowed  to  remain  in  the  wound  above  the  aponeurosis. 
For  two  or  three  weeks  she  continued  to  attend  as  an  out- 
patient, but  the  pain  then  became  so  continuous  and  so 
distressing  that  she  was  very  glad  to  consent  to  the  fistula 
being  reestablished.  During  this  time  she  lost  flesh  and 
was  readmitted  on  January  23,  1904.  The  urine  was  nor- 
mal. On  the  26th  she  was  aneesthetized  and  a  small  in- 
cision was  made  into  the  gall-bladder  over  the  closed 
sinus,  and  the  mucous  membrane  was  sutured  to  the  skin. 
A  considerable  quantity  of  mucus  with  some  purulent 
dregs  escaped,  but  no  stone  could  be  felt  with  a  probe. 
The  intense  pain  was  relieved  by  the  operation,  but  the 
patient  did  not  seem  to  recover  her  spirits.  On  January' 
28  she  had  a  rigor  and  the  temperature  rose  to  105°. 
She  had  another  rigor  on  the   29th   (temperature   102°). 


Malignant  Disease  105 

and  on  February  4  the  temperature  rose  to  103°  and  gradu- 
ally fell ;  but  with  these  exceptions  the  temperature  kept 
about  the  normal  throughout.  The  pulse  varied  from  72 
to  100,  but  it  averaged  from  80  to  90.  Two  or  three  days 
after  the  first  rigor  jaundice  was  first  noticed  and  marked 
tenderness  on  pressure  was  present  in  the  middle  line 
above  the  umbilicus.  The  jaundice  increased  and  was 
evidently  due  to  obstruction.  The  left  lobe  of  the  liver 
enlarged  and  reached  almost  to  the  umbilicus,  and  all 
o\'er  it  was  very  tender.  There  was  also  much  pain  in  the 
right  hypochondrium  and  around  the  right  lower  ribs.  The 
mucus  coming  from  the  gall-bladder  became  bile-stained. 

The  patient  complained  of  feeling  very  ill,  was  listless, 
and  often  drowsy.  Albumin  appeared  in  the  urine  and 
there  was  oedema  of  the  legs  and  abdominal  wall.  Grad- 
ually she  passed  into  a  semi-conscious  state.  Petechial 
vesicles  appeared  over  the  body  and  she  died  on  February 
17,  1904. 

Mr.  Gruner,  the  pathologist,  examined  the  blood  on 
February  8,  and  reported  as  follows : 

"Red  cells,  480,000  per  c.mm.  White  cells,  10,000  per 
c.mm.  The  neutrophile  leucocytes  predominated.  This 
result  is  quite  in  accordance  with  the  blood-find  in  cases 
of  malignant  disease.  " 

Necropsy. — Abdomen. — The  liver  was  somewhat  en- 
larged. On  laying  open  the  gall-bladder  through  the 
fistulous  opening  it  was  found  to  be  the  seat  of  malignant 
disease.  The  walls  of  the  gall-bladder  were  infiltrated 
with  growth  to  the  thickness  of  nearly  one-half  inch,  and 
the  growth  extended  to  and  involved  the  cystic  duct,  prac- 
tically occluding  it.  No  growth  involved  the  common  he- 
patic or  the  common  bile-ducts,  but  the  growth  involving 
the  cystic  duct  had  pressed  upon  and  partially  obstructed 
the  commencement  of  the  common  duct.  Above  this 
stricture  the  ducts  were  markedly  dilated  and  were  the 
seat  of  suppurative  cholangitis. 


io6     General  Pathology  of  Gall-stone  Disease 

The  surface  of  the  liver  showed  numerous  cystic  eleva- 
tions due  to  the  dilated  terminal  ducts,  and  on  section 
the  dilated  bile-ducts  were  found  filled  with  pus.  A  small 
secondary  nodule  of  growth  was  present  in  the  left  lobe 
near  its  anterior  margin.  Xo  gall-stones  were  found. 
The  pancreas  was  normal.  The  kidneys  were  small  and 
slightly  granular — other  organs  normal. 

Chest. — There  were  some  adhesions  in  both  pleural 
cavities  and  both  lungs  were  the  seat  of  chronic  bron- 
chitis. 

A  microscopic  examination  of  the  growth  of  the  gall- 
bladder showed  it  to  be  a  columnar  carcinoma. 

Changes  in  the  Liver. — In  cases  of  obstruction  of  the 
common  or  hepatic  ducts  the  li\'er,  when  examined  during 
life,  is  found  in  the  early  stages  to  have  undergone  a  con- 
siderable enlargement,  reaching  perhaps  down  to  the  um- 
bilicus ;  in  the  later  stages  the  liver  gradually  shrinks  and 
eventually  may  become  verv^  much  smaller  than  the  nor- 
mal. The  condition  of  enlargement  of  the  liver  or  hyper- 
trophv,  as  it  is  often  called,  may  persist  for  many  months. 
During  each  successive  attack  of  inflammation  in  the 
ducts,  as  shewn  by  an  elevation  of  temperature  and  rigor, 
and  an  increase  in  the  depth  of  the  jaundice,  a  slight  fur- 
ther increase  in  the  size  of  the  liver  is  commonly  observed, 
and  palpation  shews  that  the  liver  is  also  tender  upon 
pressure.  If  a  liver  be  examined  in  this  stage,  after  death, 
it  is  seen  that  the  hepatic  ducts  have  undergone  a  consid- 
erable dilatation,  so  that  a  series  of  cysts,  as  it  were,  are 
formed  in  the  liver.  The  outer  surface  of  the  liver  may 
also  be  irregularly  raised,  the  dilated  ducts  forming 
smooth,  spherical  protuberances  upon  its  surface.  These 
cysts  contain    bile    almost    always;    in   some    cases    fine 


Riedel's  Lobe  107 

calculi ;  or  a  biliary  sand,  or  mud,  consisting  chiefly  of 
bilirubin  calcium,  may  be  found  therein.  In  cases  of 
complete  obstruction  of  the  common  duct,  supervening 
upon  an  incomplete  obstruction,  the  fluid  may  consist 
of  mucus  alone,  or  of  mucus  faintly  tinged  with  bile. 
In  the  worst  examples  the  absence  of  bile,  acholia,  may 
be  due  to  a  profound  alteration  in  the  hepatic  cells. 

In  the  condition  of  atrophy  of  the  liver  a  section  of 
the  organ  shews  the  same  dilatation  of  the  hepatic  ducts, 
but  the  liver  tissue  is  in  greater  or  less  measure  replaced 
by  fibrous  tissue.  The  histological  changes  in  all  cases 
consists  of  a  biliary  cirrhosis  on  the  dilatation  of  the 
hepatic  ducts.  Many  of  the  bile  channels  may  at  the 
last  be  so  thoroughly  strangled  by  the  abundant  deposit 
of  fibrous  tissue  that  they  lose  their  epithelium  and 
finally  disappear  altogether.  The  vessels  of  the  liver 
similarly  undergo  constriction,  and  the  hepatic  cells  are 
in  parts  strangled  out  of  existence. 

If  these  conditions  are  associated  with  a  virulent  in- 
fection, the  condition  of  biliary  abscess  already  described 
will  result. 

Riedel's  Lobe. — One  remarkable  change,  which  though 
commonly  is  not  invariably  associated  with  the  pres- 
ence in  the  gall-bladder  of  a  number  of  calculi,  is  the 
formation  of  a  tongue-shaped  process  which  projects 
downwards  from  the  right  lobe  of  the  liver.  This  process 
may  have  many  forms  and  may  take  its  origin  from  the 
margin  of  the  liver  to  the  right  or  to  the  left  of  the  gall- 
bladder. It  was  first  descr  bed  by  Cruveilhier,  and  in 
the  instance  given  by  him  the  gall-bladder  contained 
manv  stones.     It  is  to  Riedel  that  we  are  indebted  for 


io8     General  Pathology  of   Gall-stone  Disease 

the  fullest  and  most  accurate  description  of  this  "  lingui- 
form  process,"  as  he  termed  it.  He  describes  (Berlin, 
klin.  Woch.,  1888,  Nos.  29  and  30)  and  figures  eight 
forms  of  the  process,  and  emphasises  its  dependence 
upon  gall-stone  disease.  He  expresses  the  opinion  that 
the  gall-bladder  in  its  enlargement  gradually  drags  down- 
wards this  tongue-shaped  lobe  of  the  liver.  In  recogni- 
tion of  his  work  the  process  is  generally  described  as 
"Riedel's  lobe."  Riedel,  Terrier,  and  other  observers 
have  asserted  that  after  cholecystotomy  the  projecting 
lobe  gradually  shrinks,  and  the  liver  then  assumes  its 
normal  outline.  In  a  very  thin  woman,  upon  whom  I 
performed  cholecystectomy,  a  lobe,  at  least  three  inches 
in  length,  has  almost  disappeared  in  the  course  of  eighteen 
months.  The  lobe  may  be  long  or  short,  its  pedicle 
may  be  thick  or  thin,  it  may  overlie  the  gall-bladder 
or  be  placed  to  its  inner  or  outer  side.  As  a  rule,  the  liver 
substance  in  the  lobe  is  greatly  altered  from  the  normal, 
being  paler  in  colour  and  more  fibrous  in  texture.  The 
tumour  is  often  recognisable,  clinically,  as  a  smooth, 
solid,  elastic  tumour,  sometimes  very  freely  movable 
("floating  lobe"),  sometimes  fixed  by  adhesion.  It 
has  been  mistaken  for  a  distended  gall-bladder,  a  mov- 
able kidney  a  hydatid  cyst  of  the  liver,  a  tumour  of 
the  omentum,  or  an  abscess. 

I  have,  on  one  or  two  occasions,  seen  a  well-marked 
Riedel 's  lobe  when  operating  upon  other  abdominal 
conditions,  in  the  absence  of  gall-stones. 


CHAPTER  IV. 

THE  SYMPTOMS  AND  SIGNS  OF  GALL-STONE 
DISEASE. 

Gall-stones  are  present  in  approximately  lo  per  cent. 
of  all  bodies  examined  on  the  postmortem  table.  The 
exact  percentages  given  by  various  writers  are  as  fol- 
lows : 

Riedel    lo  per  cent. 

Kehr lo  " 

Brewer 12  " 

Recklinghausen 12.2  " 

Reports  of    the    Johns   Hopkins    Hospital 

(Mosher) 6.94 

Herter  (Presbyterian  Hospital,  New  York) ...  7.6  " 

And  Naunyn  writes :  ' '  On  an  average  every  tenth  human 
being,  and  of  elderly  women,  perhaps  every  fourth,  has 
gall-stones."  Djakanow,  on  the  other  hand,  states  that 
gall-stones  are  very  rare  in  Russia.  In  the  very  great 
majority  of  these  cases  the  stones  have  never  given  rise 
to  symptoms  of  sufficient  severity  to  have  caused  them 
to  be  recognised  during  life.  In  probably  nine  persons 
out  of  ten  who  carry  gall-stones  the  disease  is  never 
recognised.  Gall-stones  have  been  passed,  being  found 
in  the  faeces  when  no  symptoms  of  their  presence  have 
been  elicited  within  a  recent  period.  In  such  cases, 
probably  without  exception,  there  have  been  previous 
attacks  of  gall-stone  trouble,  and  a  fistula  has  formed 

log 


iio    Symptoms  and  Signs  of  Gall-stone  Disease 

between  the  biliary  passages  and  the  bowel.  It  is  through 
the  fistula  and  not  along  the  ducts  that  the  stones  have 
passed.  In  one  patient,  a  woman  of  seventy,  I  saw  several 
stones  almost  unaltered  in  appearance  in  the  faeces. 
They  were  passed  without  any  warning  symptoms  of  gall- 
stone colic,  or  pain,  or  temperature,  or  jaundice,  though 
all  these  symptoms  had  been  present  over  thirty  years 
earlier.  About  four  years  after  I  saw  her  she  died  from 
other  causes,  and  a  fistula  between  the  gall-bladder  and 
colon  was  found. 

This  point,  as  to  the  infrequency  of  the  recognition 
of  gall-stones,  requires  emphasis,  for  it  shews  clearly 
enough  that  if  gall-stones  can  be  brought  to  lie  quietly 
in  the  gall-bladder,  there  may  be  a  complete  immunity 
from  all  suffering.  There  is  need,  however,  for  some 
qualification  in  the  statement  so  tersely  made,  for,  in 
the  first  place,  it  is  an  undoubted  fact  that  the  com- 
monest manifestation  of  the  presence  of  gall-stones  is 
never  referred  by  the  patient,  and  rarely  by  the  medical 
man,  to  the  gall-bladder  or  bile-ducts.  The  most  cursory 
examination  into  the  history  of  a  long  series  of  cases 
treated  by  operation  will  show  that,  in  almost  all,  the 
earliest  symptom,  that  which  has  for  years  caused  in- 
tense suffering  at  times,  is  "indigestion."  The  variety 
of  names  given  to  the  symptoms  of  epigastric  pain, 
nausea,  and  vomiting  is  infinite:  "indigestion,"  "gas- 
tric catarrh,"  "neuralgia  of  the  stomach,"  "spasms," 
"flatulent  distension  of  the  stomach,"  are  a  few  of  those 
most  frequently  encountered.  They  all,  as  can  be  seen, 
refer  the  trouble  to  the  stomach,  and  not  to  the  liver. 
It  requires  the    unmistakable    evidence    of   jaundice  to 


Pain  1 1 1 

associate  the  suffering  with  gall-stones  in  the  minds  of 
all  patients,  and  of  not  a  few  medical  men,  yet  jaundice 
is  an  infrequent  and  an  inconstant  s3^mptom  of  gall- 
stone disease. 

In  the  second  place,  it  must  not  be  assumed  that, 
though  no  momentous  symptoms  of  gall-stone  irrita- 
tion are  present,  all  is  yet  well  with  the  patient.  In 
cases  which  come  to  operation,  where  the  most  obvious 
undoubted  symptoms  have  been  present  for  only  a 
few  weeks,  there  will  often,  one  dare  venture  to  say 
always,  be  found  abundant  evidence  of  chronic  inflamma- 
tory processes  that  have  taken  years  in  the  accomplish- 
ing, or  of  malignant  disease  that  is  but  the  expression 
of  long-persisting  local  irritation.  It  is  not  accurate, 
therefore,  to  say  that  gall-stones,  in  the  vast  majority 
of  cases,  cause  no  symptoms.  They  cause  symptoms 
in  a  great  many  cases  where  the  true  nature  of  the  dis- 
ease is  never  recognised;  and  gall-stones  found  at  an 
autopsy  upon  a  patient  who  has  suffered  for  years  from 
gastric  disorders  may  explain  all  the  symptoms.  This 
fact,  of  the  want  of  recognition  of  gall-stone  disease,  in 
its  earliest  stages,  must  be  insisted  upon,  for  it  is  in  this 
stage  that  surgical  treatment  should,  if  possible,  be 
advised. 

The  s^^mptoms  and  signs  of  gall-stone  disease  that 
require  discussion  are  pain  and  colic,  nausea  and  vomit- 
ing, jaundice,  fever,  and  tumour. 

I.  Pain  (to  be  distinguished  from  colic,  of  which 
later  mention  will  be  made)  elicited  by  the  presence  of 
gall-stones  is  either  local  or  referred.  Localised  paui  is 
of  two  types:    a  dull  aching  pain,  due  to  increased  ten- 


112     Symptoms  and  Signs  of  Gall-stone  Disease 

sion  and  inflammation,  limited  to  the  gall-bladder;  and 
an  acute,  almost  intolerable,  pain  which  results  from 
more  intense  infection  and  a  more  widespread  inflamma- 
tion. The  dull,  localised  pain  is  generally  due  to  a 
slight  degree  of  irritation  and  inflammation,  with  a 
gradually  increasing  tension  in  the  gall-bladder  or  cystic 
ducts,  due  to  the  impaction  of  a  stone  in  its  attempt  to 
pass  out  of  the  gall-bladder.  The  pain  is  diffused  over 
a  large  area  along  and  below  the  margin  of  the  liver. 
Tenderness  is  not  specially  marked;  the  area  can  be 
examined  by  gentle  pressure  of  the  open  hand  without 
hurting  the  patient.  If,  however,  a  sudden  pressure 
be  made,  there  is  an  instant  tightening  of  the  muscles, 
which,  by  their  contraction  and  rigidity,  protect  the 
underlying  parts  from  injury.  The  best  method  of 
eliciting  tenderness  in  such  conditions  is  that  which  is 
mentioned  by  Naunyn  and  emphasised  by  Dr.  T.  B. 
Murphy,  of  Chicago,  who  writes  (Med.  News,  vol.  i,  1903, 
p.  825):  "The  most  characteristic  and  constant  sign  of 
gall-bladder  hypersensitiveness  is  the  inability  of  the 
patient  to  take  a  full  inspiration  when  the  physician's 
fingers  are  hooked  up  deep  beneath  the  right  costal  arch 
below  the  hepatic  margin.  The  diaphragm  forces  the 
liver  down  until  the  sensitive  gall-bladder  reaches  the 
examining  fingers,  when  the  inspiration  suddenly  ceases 
as  though  it  had  been  shut  oft'.  I  have  never  found 
this  sign  absent  in  a  case  of  calculus  or  in  infectious  cases 
of  gall-bladder  or  duct  disease." 

Naunyn  writes  (p.  79) :  "If  the  liver  is  swollen  as  the 
result  of  the  attack  (that  is,  recently),  the  organ  is  always 
more  or  less   tender,   and  often  very  acutely  so ;    but 


Pain 


113 


frequently  it  is  tender  without  being  swollen.  In  such 
cases  it  is  found  that  pain  is  induced  when,  during  a 
deep  inspiration,  pressure  is  made  with  the  hand  as  far 
upwards  as  possible  beneath  the  right  costal  border. 
At  the  moment  when  the  liver  impinges  upon  the  tips 


Fig.    ^S. — Method  of  cxainination  to  elicit  tenderness  of  e;all-bladder. 


of  the  fingers  the  patient  experiences  a  deep-seated  pain 
which  sometimes  radiates  over  the  entire  hepatic  region 
and  on  to  the  epigastrium."    ■ 

By  no  means  rarely,  however,  the  tenderness  of  the 
liver  is  only  manifested  by  tension  of  the  muscles  of  the 
anterior  abdominal  wall  on  the  right  side,  and  in  such 
8 


I  14    Symptoms  and  Signs  of  Gall-stone  Disease 

cases  the  difference  in  tension  of  the  right  and  left  side 
is  best  observed  in  the  upper  part  of  the  rectus.  I  have 
found  the  simplest  method  of  eliciting  the  pressure  signs 
to  be  this:  While  the  surgeon  sits  on  the  edge  of  the 
couch,  to  the  right  of  the  patient,  the  left  hand  is  laid 
over  the  lower  part  of  the  right  side  of  the  patient's  chest, 
so  that  the  thumb  lies  along  the  rib-margin;  as  a  deep 
breath  is  taken  the  thumb  is  pressed  upwards  towards 
the  under  surface  of  the  liver.  Figure  38  shews  the 
position. 

This  variety  of  pain  is  apt  to  be  confounded  with  that 
due  to  diseases  of  the  stomach.  It  is  a  dull,  rather  diffuse 
aching,  which  is  often  worse  after  food,  and  is  almost 
without  exception  relieved  by  vomiting.  The  pain  is 
due  to  the  impaction  of  a  stone  and  the  gradual  increase 
in  tension  within  the  gall-bladder.  As  soon  as  the  stone 
falls  back  into  the  gall-bladder,  as  it  often  does  after  the 
act  of  vomiting,  the  pain  is  relieved.  It  is  readily  under- 
stood, therefore,  that  the  act  of  emptying  the  stomach  is 
supposed  to  have  given  relief  to  that  organ.  The  pain, 
however,  is  sometimes  more  acute  than  that  described,  and 
is  the  expression  of  a  higher  degree  of  irritation  and  of 
consecutive  inflammation  in  the  gall-bladder  and  ducts, 
and  perhaps  also  of  the  peritoneum  surrounding  them. 
The  pain,  whether  mild  or  grave,  is  certainly  due  to  in- 
flammatory^ action,  and  probably  indicates  that  the  peri- 
toneum is  involved.  When  the  irritation  caused  by  the 
stone  is  slight,  when  its  impaction  is  but  of  brief  duration, 
the  inflammation  which  is  set  up  is  trivial  and  evanescent ; 
when  impaction  is  more  prolonged,  a  cholecystitis  or  a 
cholangitis  is  not  long  delayed,  and  the  pain  becomes, 


Pain 


115 


therefore,  more  acute,  and  the  peritoneal  investment 
of  the  bladder  and  ducts  becomes  more  widely  impli- 
cated. That  inflammation  is  the  cause  of  the  pain, 
and  that  the  inflammation  is  the  result  of  an  infection 
due  to  the  irritation  of  a  stone,  there  can  be  no  doubt. 
When  the  dull,  aching,  constant  pain  has  been  present  for 
years  and  the  gall-bladder  be  examined,  its  walls  are 
found  thickened,  toughened,  and  fibrous;  there  may  be 
little  or  no  evidence  of  surrounding  peritonitis.  When, 
however,  the  pain  has  been  more  severe,  and  especially 
when  there  has  been  a  marked  rigidity  of  the  muscles 
overlying  the  gall-bladder,  evidence  of  peritonitis  in  the 
form  of  adhesions,  more  or  less  complex,  will  be  found. 
The  dull,  aching  pain,  elicited  by  thumb  pressure,  and  the 
acute,  more  wide-spread  pain,  with  muscular  rigidity,  are, 
therefore,  both  due  to  an  infection  and  inflammation. 
In  the  former  the  inflammation  is  limited  to  the  gall-blad- 
der, producing  gross  degeneration  of  its  coats ;  in  the  lat- 
ter the  inflammation  spreads  to  the  surrounding  peri- 
toneum and  causes  the  outpouring  of  lymph,  and,  at  the 
last,  a  complex  entanglement  of  the  gall-bladder  and  its 
surroundings  in  dense  and  tough  adhesions.  The  local- 
ised pain  of  cholelithiasis  is  almost  always  made  easier  by 
steady,  even  pressure ;  the  radiating  pains  are  unaffected. 

The  referred  pain  is  almost  always,  though  not  in- 
variably, associated  with  one  or  the  other  of  the  foregoing. 
The  pain  radiates  to  the  right  subscapula  •  region,  rarelv 
to  the  left;  to  the  neck,  or  down  the  arm,  and  to  the 
epigastric  region.  According  to  Murphy,  in  obstructions 
to  the  pelvis  of  the  gall-bladder  or  to  the  cystic  duct,  the 
pain  is  referred,  on  an  average,  in  seven  cases  out  of  ten, 


ii6    Symptoms  and  Signs  of  Gall-stone  Disease 

to  the  right  subscapular  region;  in  one  case,  to  the  left 
subscapular  region;  and  in  two  cases  out  of  ten,  to  the 
front  of  the  chest  as  high  as  the  neck.  This  computation 
is  based  upon  repeated  soundings  and  irritations  after 
cholecy  stotomy . 

The  existence  of  an  area  of  referred  tenderness  in  gall- 
stone disease  is  described  by  Boas.  He  finds  that  in  a 
majority  of  patients  suffering  from  cholelithiasis  there  is 
an  area  of  increased  tenderness,  on  pressure,  on  the  right 
side  behind,  on  a  level  with  the  twelfth  thoracic  vertebra, 
two  or  three  fingersbreadth  from  the  spine.  At  a  cor- 
responding point  on  the  left  side  no  tenderness  is  found. 
This  symptom  may  be  present  even  when  there  is  no  ten- 
derness over  the  gall-bladder  or  beneath  the  margin  of 
the  liver. 

Boas  writes  (Miinch.  med.  Woch.,  April  15,  p.  604): 

"  Least  recognised  as  a  symptom  of  cholelithiasis  is 
tenderness  over  the  posterior  surface  of  the  liver.  When 
well  marked  it  extends  laterally  from  about  an  inch  exter- 
nal to  the  spines  of  the  vertebras  to  the  posterior  axillary 
line,  and  vertically  from  the  eleventh  dorsal  to  the  first 
lumbar  spines.  To  demonstrate  it  the  finger  should  be 
pressed  against  a  point  to  the  right  side  of  the  tenth 
dorsal  spine ;  then  against  successive  points  in  lines  run- 
ning horizontally  outwards,  opposite  the  other  spinous  pro- 
cesses, down  to  the  first  lumbar  spine,  first  on  one  side, 
then  on  the  other.  It  is  then  evident  which  side  is  the 
more  tender.  This  symptom,  if  present  during  the  acute 
attack,  is  also  invariably  present  in  the  intervals;  that  is, 
if  once  present,  it  is  always  present,  and  is  therefore  of 
special  diagnostic  value  in  the  latent  stages.  Occasionally 
it  may  be  found  years  after  the  last  attack  of  colic.     Con- 


Pain  1 1 7 

versely,  if  absent  in  the  acute  attack,  it  is  not  found  in  the 
intervals.  It  is  usually  sufficient  to  map  out  the  areas  of 
tenderness  with  the  finger ;  but  when  there  is  a  doubt  as  to 
whether  the  right  side  is  the  more  tender,  greater  accuracy 
may  be  obtained  with  the  faradic  or  galvanic  current. 
When,  as  often  occurs,  the  lower  edges  of  the  liver  and  the 
gall-bladder  are  not  tender,  the  discovery  of  the  second 
or  third  areas  of  tenderness  may,  in  conjunction  with 
other  symptoms,  often  decide  the  diagnosis.  The  pres- 
ence of  one  or  more  of  these  areas  indicates  also  that 
though  no  attack  of  colic  may  have  occurred  for  some 
time,  the  patient  still  requires  supervision  and  treat- 
ment. " 

I  consider  the  search  for  this  tender  area  a  necessary 
part  of  the  examination  of  all  patients  who  suffer  from 
gall-stone  disease,  or  in  whom  the  existence  of  this  dis- 
ease is  suspected.     It  is  undoubtedly  a  sign  of  great  value. 

Colic. — The  pain  experienced  as  a  result  of  the  irri- 
tation of  gall-stones  is  often  colicky  in  character.  The 
exact  cause  of  the  colic  has  been  much  debated,  and  at  the 
present  time  there  seems  to  be  no  likelihood  of  general 
agreement  upon  the  question.  Kehr,  Riedel,  and  others 
take  the  view  that  the  colic  is  often  or  solely  due  to  an 
inflammatory  response  to  irritation  in  the  gall-bladder 
or  in  some  part  of  the  ducts.  They  consider  that  the 
cholangitis  so  aroused  lessens  the  calibre  of  the  ducts, 
impedes  the  onward  passage  of  their  contents,  causes  an 
increased  pressure  behind  the  obstruction,  and  so  gives 
rise  to  the  colic. 

Riedel  tabulates  the  following  as  causes  of  gall-stone 
colic : 


1 1 8    Symptoms  and  Signs  of  Gall-stone  Disease 

1.  Adhesions  of  a  gall-bladder  no  longer  containing 

stones.  There  is  a  circumscribed  peritoneal  irri- 
tation, with  abdominal  distension,  more  or  less 
severe  vomiting,  and  pain. 

2.  Adhesions  when  large  stones  are  present  in  the  gall- 

bladder and  the  cystic  duct  is  patent. 

3.  Inflammatory  processes  in  a  gall-bladder  distended 

by  fluid  or  stones ,  when  the  cystic  duct  is  occluded 
by  inflammation  or  by  the  presence  of  a  stone  in  the 
neck  of  the  gall-bladder. 

4.  The  transit  of  a  stone  through  the  bile  passages. 

5.  The  inflammation  of  a  dilated,  calculous  common 

duct,  or  its  tributaries,  without  impaction  of  the 
stone. 

Riedel  is  of  the  opinion  that  a  hydrops  of  the  gall-blad- 
der is  present  in  all  cases  where  the  onset  of  the  attack 
is  sudden,  as  it  is  when  a  stone  is  about  to  be  passed.  If 
closure  of  the  cystic  duct  is  not  present,  the  sudden  onset 
of  gall-stone  colic  is  rare.  The  absence  of  symptoms 
in  so  many  patients  whose  gall-bladders  contain  stones 
is  due  to  the  fact  that  the  cystic  duct  remains  patent. 

On  the  other  hand,  many  surgeons  consider  that  the 
colic  is  always  and  inevitably  due  to  spasm  of  the  duct; 
that  it  is  in  the  attempt  of  the  duct,  by  overcontraction 
of  its  muscle,  to  expel  an  impacted  body,  that  the  cause 
of  the  colic  is  to  be  found.  The  characteristics  of  the 
colicky  pain  are  the  abruptness  of  its  onset  and  the 
suddenness  of  relief.  These  are  incompatible  with  any- 
thing which  is  inflammatory  in  character,  and  can  only 
be  explained  by  the  sudden  entrance  and  the  equally 
sudden  exit  of  a  foreign  body.  The  colic  is  due,  therefore, 
to  the  passage  of  a  stone  or  a  foreign  body  of  some  kind 


Pain  119 

(a  hydatid  cyst,  for  example,  I  have  once  seen)  down 
the  ducts.  The  pain  endures  just  so  long  as  the  body 
is  moving.  If  impaction  and  fixity  of  the  stone  occur, 
the  pain  gradually  lessens,  and  at  length,  probably 
after  a  few  hours,  disappears  entirely,  to  be  roused 
afresh  when  a  further  movement  occurs. 

Many  surgeons  have  remarked  that  a  high  degree  of 
infection  of  the  gall-bladder  and  of  the  ducts  may  be 
present  when  no  colic  is  or  has  ever  been  noticed.  Both 
Riedel  and  Kehr,  indeed,  have  given  exemplary  instances 
of  both;  of  cases,  that  is  to  say,  in  which  inflammation 
has  been  present  without  colic. 

An  attack  of  colic  or  of  spasm  is  caused,  therefore, 
only  by  an  overexertion,  of  the  nature  of  cramp,  of  the 
muscular  wall  of  the  gall-bladder  or  ducts  in  the  onward 
passage  of  a  foreign  body.  It  is  never  found  as  the  result 
of  a  gradually  increasing  distension  of  the  gall-bladder  or 
ducts;  it  is  not  aroused  by  inflammation,  wdiether  acute 
or  chronic,  in  any  part  of  the  bile- tract;  it  is  not  found 
in  cicatricial  stenosis,  nor  in  those  cases  in  which  a  grad- 
ually increasing  pressure  is  made  upon  the  ducts  from 
without.  It  is  due  to  the  sudden  blockage  of  the  ducts  and 
to  their  exaggerated  muscular  efforts  to  rid  themselves 
of  the  foreign  body.  It  occurs  only  when  this  foreign 
body  is  in  transit.  As  soon  as  the  body  becomes  fixed 
the  muscular  efforts  slacken  and  cease,  and  the  ducts 
proceed  to  adapt  themselves  to  the  intruder.  Small  stones 
may  pass  along  the  cystic  and  common  ducts  without 
exciting  pain.  During  operations  for  the  removal  of 
stones  from  the  gall-bladder  I  have  occasionally  demon- 
strated  the  presence   of  small  pebbles   in   the  common 


I20    Symptoms  and  Signs  of  Gall-stone  Disease 

duct  which  have  lain  there  without  producing  symptoms. 
The  colic,  when  severe,  is  probably  as  terrible  a  suffering 
as  a  patient  is  ever  called  upon  to  endure.  It  comes 
on  with  absolute  suddenness,  produces  a  degree  of  col- 
lapse that  may  be  profound,  and  soon  induces  faintness, 
sickness,  and  vomiting.  The  patient  has  terror  written  in 
every  line  of  an  anxious  face.  He  is  cold,  and  yet  sweats 
profusely.  His  general  condition,  indeed,  is  at  times 
alarming.  The  pain  is  often  said  by  patients  to  "  double 
them  up."  In  their  agony  some  slight  relief  seems  to 
be  gained  by  bending  from  the  waist  over  a  chair  or 
couch,  or,  when  sitting,  by  folding  the  arms  across  the 
epigastrium  and  by  forcible  flexion  of  the  trunk.  To 
see  such  a  patient  in  the  utmost  extremity  of  his  suffer- 
ing is  enough  to  convince  one  that  a  spasm,  similar  to 
the  spasm  of  the  intestine  or  of  the  ureter,  is  the  cause 
of  the  intolerable  pain. 

This  hepatic  colic  is  the  most  characteristic  and  the 
most  commonly  recognised  form  of  pain  associated  with 
gall-stones.  It  is  present,  however,  in  those  cases  only 
in  which  a  stone  is  recently  impacted  or  is  in  transit  in 
the  ducts.  Since  in  the  vast  majority  of  patients  a  stone 
never  enters  on  its  travels  from  the  gall-bladder,  it  is 
quite  clear  that  hepatic  colic  is  a  far  less  frequently  ob- 
served symptom  than  the  dull,  or  the  more  acute,  localised 
pains  which  have  been  previously  mentioned. 

If  the  stone  while  in  passage  through  the  ducts  becomes 
for  any  reason  arrested,  the  colic  gradually  ceases  and 
in  a  few  hours  disappears.  The  stone  may  rest  in  its 
position  for  many  years  without  causing  spasm,  but  the 
moment  it  attempts  to  resume  its  journey  the  pain  will 


Pain 


121 


surely  return  and  the  colic  will  be  as  severe  as  before. 
Murphy  has  called  attention  to  the  fact  that  pain  of  the 
same  character  may  be  caused  by  the  backward  move- 
ment of  a  stone,  as,  for  example,  after  a  cholecystotomy, 
when  a  stone,  impacted  in  the  cystic  duct,  works  its 
way  backwards  into  the  gall-bladder.  Vermicular  con- 
tractions of  the  gall-bladder  or  of  the  bile-ducts  have 
never,  so  far  as  I  am  aware,  been  observed  in  man; 
but  spasmodic  muscular  contractions  of  the  wall  of 
the  gall-bladder  and  bile-ducts  were  observed  by  Haller 
and  Miiller  in  pigeons.  Doyen  and  Oddi  have  observed 
them  in  rabbits,  dogs,  and  cats.  Simanowski  was  able 
to  recognise  spasm  in  the  common  bile-duct  in  animals, 
when  foreign  bodies  were  introduced  into  its  lumen. 
A  muscular  hypertrophy  has,  however,  been  not  infre- 
quently found  in  the  gall-bladder,  and  in  some  cases  this 
may  be  so  exaggerated  as  to  cause  the  upraising  of 
muscular  bundles  in  the  wall.  Schiippel  has  described 
a  specimen  in  which  a  fasciculation,  similar  to  that  seen 
in  the  urinary  bladder,  is  found. 

Gall-stones,  it  will  be  seen,  cause  pain,  and  therefore 
elicit  recognition  in  one  or  two  ways.  Firstly,  by  causing 
irritation,  infection,  and  inflammation  as  a  result  of 
their  impaction  in  the  neck  of  the  gall-bladder  or  in  any 
part  .of  the  ducts.  Secondly,  by  traversing  the  ducts 
for  a  shorter  or  a  longer  distance,  and  in  their  movement 
setting  up  a  spasm  of  the  muscular  wall,  behind  the  stone. 
The  pain  caused  in  the  former  manner  is,  in  some  cases, 
a  dull,  in  other  cases  an  acute,  pain,  limited  generally  to 
the  gall-bladder  area.  The  pain  caused  in  the  latter 
manner  is  a  spasmodic,  colicky  pain.     In  both  there  are 


122     Symptoms  and  Signs  of  Gall-stone  Disease 

radiating  pains,  spreading  away  from  the  gall-bladder 
region,  sometimes  to  the  right  shoulder-blade,  some- 
times to  the  left,  sometimes  to  the  front  of  the  abdomen 
and  chest. 

There  has  been  a  prolonged  and  a  somewhat  heated 
discussion  as  to  the  exact  cause  of  the  colicky  pains  in 
gall-stone  disease.  It  is  held  by  Riedel,  Kehr,  and  others 
that  the  colic  is  due,  as  a  rule,  to  infection  and  inflam- 
mation in  the  gall-bladder  or  the  bile-ducts;  by  others, 
chief  among  whom  is  Murphy,  it  is  asserted  that  colic  is 
due  to  spasm  of  the  gall-bladder  or  ducts,  and  is  an 
indication  of  the  fact  that  a  stone  or  other  foreign  body 
is  in  transit  through  the  ducts.  Kehr  writes:  "  The  gall- 
stone colic  depends  almost  always  upon  an  inflammation 
of  the  gall-bladder,"  and,  again,  "The  inflammation 
causes  pain  since  the  secretion  collecting  in  the  hollow 
organ  stretches  its  walls."  There  can  be  no  doubt 
whatever  that  in  the  great  majority,  if  not  in  all,  opera- 
tions upon  patients  who  have  suffered  from  attacks  of 
gall-stone  colic  there  is  evidence  of  old,  often  wide- spread, 
inflammation.  But,  although  this  must  be  allowed,  it 
does  not  explain  why  an  acute  or  subacute  inflammation, 
even  when  leading  to  distension,  should  cause  colic.  The 
distension  of  other  hollow  viscera,  as  the  result  of  inflam- 
mation, does  not  cause  colic.  With  them,  colic  signifies 
an  excessive,  ill-regulated,  spasmodic  muscular  action. 
In  cases  of  dilatation  of  the  stomach,  as  the  result  of 
pyloric  obstruction,  and  in  cases  of  intestinal  obstruction 
of  slow  onset,  a  visible  peristalsis  can  be  recognised.  It 
is  always  found  that  the  onset  of  a  colicky  pain  coincides 
with,  and  by  the  patient  is  recognised  as  being  due  to, 


Nausea  and  Vomiting  123 

a  well-marked  spasmodic  muscular  contraction  of  the 
wall  of  the  viscus.  In  the  passage  of  a  stone  down  the 
ureter  the  pain  is  always  colicky  in  character.  In  fact, 
so  far  as  we  know,  colic  is  never  due  to  an  increased 
tension  alone ;  there  must  be  added  a  spasmodic  muscular 
contraction  in  the  walls  of  the  cavity.  In  cases  of  gall- 
stones it  is  universally  admitted  that  it  is  the  inflamma- 
tion to  which  they  give  rise  that  in  the  vast  majority  of 
cases  causes  their  recognition ;  and  it  is  the  inflammation 
which  causes  all  pains  other  than  the  colic.  Inflamma- 
tion, by  causing  an  increased  secretion  from  the  walls  of 
the  gall-bladder,  or  by  altering  the  physical  properties  of 
the  fluid  contained  therein,  may  indirectly  be  responsible 
for  the  excitation  of  a  spasm.  For  the  thickened,  ropy, 
tenacious,  or  semi-solid  bile,  or  mixture  of  bile  and  mucus, 
may,  and  almost  certainly  does,  act  as  a  foreign  body. 
In  the  transit  of  this  thickened  material  a  spasm  is  excited 
and  colic  is  experienced.  My  own  view  is  that,  though 
full  allowance  must  be  made  for  the  supreme  importance 
of  inflammation  in  cholelithiasis,  there  is  no  evidence 
that  colic  is  ever  due  to  any  other  cause  than  spasm 
of  the  muscular  wall  of  the  gall-bladder  or  ducts;  a 
spasm  that  is  excited  by  the  entrance  into,  or  the  at- 
tempted passage  through,  some  part  of  the  ducts  of  a 
stone,  of  altered  bile,  or  mucus,  or  other  irritating 
foreign  body. 

2.  Nausea  and  Vomiting. — These  are  among  the  com- 
monest of  the  manifestations  of  cholelithiasis.  It  is, 
indeed,  their  frequency  which  is  responsible  for  the  un- 
just and  heavy  burden  which  is  laid  upon  the  stomach. 
If  one  wished  to  frame  an  epigram  it  could  be  said,  with 


V 


124    Symptoms  and  Signs  of  Gall-stone  Disease 

truth,  that  the  most  common  symptom  of  gall-stones  is 
indigestion.  The  indigestion  has,  as  its  natural  and 
expected  sequence,  an  attack  of  nausea  and  vomiting, 
which  brings  relief.  The  nausea  and  vomiting  are  partly 
reflex  in  origin  and  are  partly  due  to  the  direct  irritation 
of  the  stomach.  In  the  majority  of  cases  the  feeling  of 
deadly  sickness  and  the  vomiting  which  follows  it  are 
due  to  the  impaction,  momentary  or  enduring,  of  a  stone 
in  the  cystic  duct.  Just  as  the  passage  of  a  renal  stone 
from  the  pelvis  of  the  kidney  to  the  ureter  is  attended 
by  the  sudden  feeling  of  intense  prostration  and  sickness, 
so  is  the  passage  of  a  stone  into  the  orifice  of  the  cystic 
duct.  It  is  the  obstruction  which  refiexly  produces  the 
nausea  and  the  vomiting.  The  vomiting  when  pro- 
longed produces  a  general  muscular  relaxation  and  sweat- 
ing, and  in  this  flaccid  and  enfeebled  condition  of  the 
patient  the  impacted  stone  falls  back. 

I  have,  in  one  patient,  seen  on  two  occasions  the  grad- 
ual filling  up  of  the  gall-bladder  attended  by  persistent 
vomiting.  The  patient  was  a  woman,  thirty-four  years 
of  age,  whom  I  saw  with  Dr.  Carlton  Oldfield.  She 
complained  of  attacks  of  sickness  and  constant  vomit- 
ing, and  during  these  attacks  a  lump  gradually  formed 
in  the  abdomen.  When  the  lump  vanished,  as  it  did 
almost  suddenly,  the  vomiting  ceased.  The  patient  was 
admitted  to  the  hospital  and  her  story  verified  by  obser- 
vation. She  began,  quite  suddenly,  to  suffer  from  faint- 
ness,  nausea,  and  vomiting,  and  within  a  few  hours  the 
gall-bladder  became  palpable.  Vomiting  and  enlarge- 
ment of  the  gall-bladder  continued  for  three  days  on 
one  occasion,  for  five  days  on  another,  when  the  gall- 


Jaundice  125 

bladder  disappeared  almost  suddenly  and  the  vomiting 
and  nausea  instantly  ceased.  At  the  operation  no  gall- 
stone was  found.  The  gall-bladder  was  very  large,  thick, 
and  flaccid.  The  obstruction  at  its  neck  was  due  to  a 
sharp  kink,  aided  very  probably  by  a  large  gland  lying 
close  to  the  cystic  duct. 

In  all  patients  who  suffer  from  constant  attacks  of 
nausea  and  vomiting  it  is  desirable  that  the  possibility  of 
the  existence  of  gall-stones  should  be  borne  in  mind. 
The  examination  of  such  patients  should  include  an 
attempt  to  elicit  the  pressure  sign  to  which  reference 
has  already  been  made. 

3 .  Jaundice.— Jaundice  is  a  rare  symptom  of  gall-stone 
disease,  unhappily.  If  jaundice  occurred  more  frequently 
than  it  does,  there  would  be  an  earlier  and  more  frequent 
recognition  of  the  disease.  It  is,  however,  an  inconstant, 
and  often  an  inconspicuous,  symptom.  Murphy,  whose 
experience  of  the  surgery  of  gall-stones  is  very  consider- 
able, found  that  jaundice  was  present  in  only  14  per 
cent,  of  his  patients  at  any  time  during  the  course  of 
their  disease. 

Wolff  stated  that  jaundice  was  present  in  50  percent, 
of  the  patients  in  whom  a  diagnosis  of  gall-stones  was 
warranted  by  a  discovery  of  stones  in  the  faeces.  Fiir- 
bringer  found  jaundice  is  only  25  per  cent,  of  his  cases. 

In  some  patients,  owing  to  a  natural  sallowness  of  the 
skin,  the  presence  of  jaundice  may  be  difficult  to  deter- 
mine. I  have  found  a  suggestion  made  by  Hamel  to 
be  of  great  value  in  this  and  in  like  circumstances.  A 
capillary  tube  is  taken  and  blood  allowed  to  flow  into  it 
from  a  puncture  made  in  the  lobe  of  the  ear.     After 


126    Symptoms  and  Signs  of  Gall-stone  Disease 

standing  for  a  few  hours  the  serum  should  collect  in  the 
upper  part  of  this  tube;  normally  it  is  quite  colourless, 
but  if  even  the  faintest  tinge  of  jaundice  be  present,  a 
yellow  colour  will  be  readily  perceived  in  the  serum. 

Jaundice  in  cholelithiasis  depends  upon  one  or  other  of 
two  factors :  impaction  of  a  stone  in  the  hepatic  or  com- 
mon ducts,  or,  rarely,  of  a  large  stone  in  the  cystic  duct, 
causing  pressure  on  the  common  duct;  or  infection  of 
these  ducts.  The  impaction  of  a  stone  in  the  cystic  duct 
does  not  cause  jaundice  unless  the  hepatic  or  common 
ducts  are  also  involved.  If  they  remain  intact,  jaundice 
does  not  occur. 

Jaundice  varies  greatly  in  the  character  of  its  appear- 
ances and  of  its  vanishing.  When  jaundice  is  due  to 
gall-stones  it  is,  almost  without  exception,  preceded  by 
colic.  The  pain  comes  a  few  hours  or  a  few  days  before 
the  tinge  of  jaundice  is  noticed,  and  a  rough  proportion 
holds  between  the  intensity  of  the  colic  and  the  depth 
of  the  jaundice.  The  jaundice,  as  a  rule,  appears  grad- 
ually and  deepens  more  or  less  rapidly,  according  to  the 
completeness  of  the  obstruction  to  the  onflow  of  the  bile. 
If,  after  attaining  a  certain  depth,  it  passes  gradually 
away,  the  obstruction  to  the  duct  has  been  relieved. 
If,  however,  a  stone  becomes  impacted  in  the  duct  and 
the  duct  dilates  behind  it,  a  ball-valve  action  results, 
as  shewn  by  Fenger,  and  the  jaundice  is  remittent.  It 
varies, — that  is,  in  depth  of  tinge, — but  never  clears 
completely  away.  There  is  always  a  perceptible  yellow- 
ness of  the  conjunctivas  and  of  the  skin  of  the  abdomen. 
The  degree  of  discolouration  may  vary  not  only  from  day 
to  day,  but  from  morning  to  night,  being   slighter  on 


Jaundice  127 

rising  in  the  morning  and  deepening  slowly  during  the 
day. 

If  a  stone  be  impacted  in  the  cystic  duct  it  may  give 
rise  to  jaundice  by  arousing  an  acute  inflammation  which 
spreads  down  to  the  common  duct,  and  there  causing  a 
swelling  and  thickening  of  the  mucosa,  resulting  in  an 
incomplete  block  to  the  downward  passage  of  the  bile.  If 
a  stone  be  impacted  just  as  its  tip  is  entering  the  common 
duct,  similar  attacks  of  cholangitis  are  caused.  In  both 
these  instances,  however,  the  jaundice  clears  oft"  entirely 
in  the  intervals  between  the  recurring  attacks  of  inflam- 
mation ;  that  is,  the  jaundice  is  intermittent,  not  remittent. 

By  contrast  with  this  the  form  of  jaundice  met  with 
in  malignant  disease  may  be  mentioned.  If  there  be  a 
cancer  of  the  head  of  the  pancreas,  and  obstruction  to  the 
common  duct  result  from  the  pressure  of  the  enlarging 
growth,  jaundice  will  be  a  symptom  of  the  gradually  in- 
creasing difliculty  that  the  bile  experiences  in  passing 
down  a  narrowed  channel.  The  jaundice  will  appear  quite 
gradually  and  painlessly;  it  will  deepen  day  by  day  by 
almost  imperceptible  degrees,  until  the  colour  of  the  skin 
is  a  deep  greenish  yellow.  There  will  be  neither  remissions 
nor  intermissions,  but  a  steady  and  progressive  deepening. 
Pain  is  never  present.  I  am  of  opinion  that  there  is  a 
decided  difference  in  the  colour  of  the  jaundice  in  simple 
and  in  malignant  cases.  In  the  former  the  golden-yellow 
colour,  in  the  latter,  the  green,  predominates. 

The  importance  of  the  association  of  distension  of  the 
gall-bladder  with  jaundice  was  pointed  out  many  years 
ago  by  Courvoisier.  In  the  large  series  of  cases  whose 
records  were  examined  by  Courvoisier,  it  was  found  that 


128     Symptoms  and  Signs  of  Gall-stone  Disease 

in  a  little  over  80  per  cent,  of  cases  of  gall-stones  in 
which  persisting  jaundice  was  present,  the  gall-bladder 
was  contracted.  The  infiammator}"  changes,  due  to  long- 
standing and  oft-repeated  attacks  of  infection  of  the  gall- 
bladder in  the  cases  of  impacted  stone,  result  in  a  thicken- 
ing of  its  walls  and  in  a  marked  contraction  of  its  cavity. 
In  many  cases  the  gall-bladder  is  no  thicker  than  a  lead 
pencil ;  in  others  its  cavity  will  barely  contain  the  ordi- 
nary probe.  Distension  of  such  a  gall-bladder  is  a 
physical  impossibility.  When,  therefore,  a  distended  gall- 
bladder is  found  in  association  with  jaundice,  there  is  a  very 
strong  probability  that  gall-stones  are  not  the  cause  of  the 
symptoms.  In  a  certain  number  of  such  cases  the  disten- 
sion of  the  gall-bladder  may  be  due  to  a  stone  impacted 
in  the  cystic  duct,  which  causes  recurring  waves 
of  inflammation  to  spread  along  the  cystic  to  the  com- 
mon duct,  or  the  stone  may  project  by  its  tip  from  the 
cystic  into  the  common  duct.  In  one  case  I  have  seen 
the  gall-bladder  enormously  distended  by  hydatids  which 
had  burst  into  it  from  a  large  hydatid  cyst  in  the  right 
lobe  of  the  liver ;  other  hydatids  blocked  the  common  duct 
from  end  to  end,  distending  it  to  a  diameter  of  about  one 
and  one-half  inches.  Jaundice  was,  of  course,  persistent. 
The  case,  indeed,  was  diagnosed  as  one  of  malignant  dis- 
ease of  the  pancreas;  no  operation  was  performed,  as  the 
patient  became  maniacal  and  died  within  a  few  days  of 
her  admission  to  the  Infirmary. 

Courvoisier  further  pointed  out  that  when  persisting 
jaundice  was  associated  with  distension  of  the  gall-bladder, 
the  cause  was,  in  over  90  per  cent,  of  cases,  an  obstruc- 
tion  of   the   common   duct   by   pressure   from   without. 


Jaundice 


129 


The  most  frequent  cause  in  such  circumstances  was 
mahgnant  disease  of  the  head  of  the  pancreas.  The 
exact  figures  given  by  Courvoisier  were  as  follows : 

There  were  187  cases  of  ob- 
struction of  the  common  duct 
from  all  causes.  Of  these,  100 
were  due  to  obstruction  from 
causes  other  than  stone,  and 
87  were  due  to  obstruction  by 
stone.  Of  100  cases  in  which 
the  obstruction  was  due  to 
causes  other  than  stone,  in 
92  cases  there  was  dilatation 
of  the  gall-bladder;  in  eight 
cases  there  was  a  normal  gall- 
bladder or  an  atrophy  of  the 
gall-bladder. 

Of  87  cases  in  which  the  ob- 
struction was  due  to  stone,  in 
70  cases  the  gall-bladder  was 
small  and  atrophied;  in  17 
cases  the  gall-bladder  was 
dilated. 

All  these  cases  were  col- 
lected from  the  literature.  Of 
the  cases  that  came  to  oper- 
ation and  were  recorded    by 

Courvoisier,  35  in  number,  in  18  the  obstruction  was 
due  to  causes  other  than  stone,  and  in  16  of  these  there 
was  dilatation  of  the  gall-bladder ;  in  1 7  the  obstruction 
w^as  due  to  stone,  and  in  13  of  these  the  gall-bladder  was 
9 


Fig.  39. — A  dilated  gall- 
bladder measuring  eight  by  six 
inches  due  to  cancer  of  the 
head  of  the  pancreas  (Guy's 
Hospital  Museum,  No.  1392). 


I  30    Symptoms  and  Signs  of  Gall-stone  Disease 

contracted.  In  several  cases  I  have  seen  a  chronic  indu- 
rative pancreatitis  produce  jaundice  with  an  enlarged 
gall-bladder.  These  observations  of  Courvoisier's  were 
formulated  by  him  in  the  following  statement,  which  is 
now  generally  referred  to  as  "  Courvoisier's  Law  ".• 

"In  cases  of  chronic  jaundice  due  to  blockage  of  the 
common  duct,  a  contraction  of  the  gall-bladder  signifies 
that  the  obstruction  is  due  to  stone;  a  dilatation  of  the 
gall-bladder,  that  the  obstruction  is  due  to  causes  other 
than  stone." 

The  validity  of  this  law  has  been  closely  investigated 
and  its  truth  has  been  affirmed  by  almost  every  writer. 
The  earliest  confirmation  of  it  was  afforded  by  the  inde- 
pendent observations  of  Mayo  Robson,  published  in  1892. 
He  wrote:  "Distension  of  the  gall-bladder,  accompanied 
by  jaundice,  has  in  all  the  cases  which  I  have  observed, 
and  in  those  cases  where  I  have  operated,  turned  out  to 
be  dependent  on  cancer,  either  of  the  head  of  the  pancreas 
or  of  the  common  duct." 

Ecklin,  in  172  cases  of  common  duct  obstruction,  due 
to  calculus,  found  that  28,  or  16  per  cent.,  had  dilatation 
of  the  gall-bladder;  144,  or  84  per  cent.,  had  contraction 
of  the  gall-bladder.  In  139  cases  of  obstruction  due  to 
other  causes  121,  or  87  per  cent.,  had  dilatation  of  the 
gall-bladder. 

A  further  examination  of  the  question  has  been  made 
by  Dr.  A.  Cabot,  of  Boston,  who  collected  the  records 
of  the  Massachusetts  Hospital.  There  were  86  cases  of 
obstruction  of  the  common  duct.  Of  these,  5  7  were  due  to 
obstruction  by  stone ;  in  47  the  gall-bladder  was  atrophied. 


Jaundice  131 

in  eight  it  was  normal,  and  in  two  enlarged.  Twenty- 
nine  cases  were  due  to  causes  other  than  stone ;  in  2  7  the 
gall-bladder  was  distended ;  in  one  the  gall-bladder  was 
empty,  and  in  one  contracted  around  three  stones.  Only 
four  cases,  therefore,  in  this  series  did  not  fall  in  with 
Courvoisier's  law.  Cabot  writes:  "With  the  exception 
of  these  four  cases,  which  constitute  only  5  per  cent,  of 
the  total  number  examined,  every  record  of  the  Massa- 
chusetts Hospital  series  in  which  definite  statements  are 
to  be  found  concerning  the  points  at  issue  goes  to  confirm 
Courvoisier's  law." 

The  explanation  given  by  Courvoisier  of  the  occurrence 
of  sclerosis  of  the  gall-bladder  in  cases  of  stone  was  that 
the  presence  of  calculi  in  the  gall-bladder,  and  their  pas- 
sage or  attempted  passage  down  the  ducts,  had  caused 
irritation  and  inflammation  in  and  around  the  bile 
passage.  Cholecystitis  and  peritonitis  were  the  result 
and  had  resulted  in  the  cicatricial  cramping  and  compres- 
sion of  the  gall-bladder. 

Fenger,  criticising  this  statement,  offers  the  explana- 
tion that  "  the  atrophy  in  these  cases,  hitherto  incom- 
prehensible, is  easily  explained  by  the  ball- valve  action 
of  a  floating  choledochus-stone  at  the  distal  end  of  the 
cystic  duct."  This,  however,  leaves  out  of  considera- 
tion the  numerous  cases  where  the  stone  is  not  found 
at  the  spot  mentioned.  Elsewhere  Fenger  attributes 
the  emptiness  of  the  gall-bladder  to  a  floating  stone 
"in  or  near  the  cystic  duct." 

The  great  probability  is  that  the  explanation  of  Cour- 
voisier is  entirely  correct.  The  sclerosis  of  the  gall- 
bladder is  a  matter  of  old  standing  and  is  present  long 


132     Symptoms  and  Signs  of  Gall-stone  Disease 

before  the  impaction  of  the  stone.  Fenger's  explana- 
tion would  account  for  the  emptiness  of  the  gall-bladder 
in  a  few  cases,  but  not  for  the  cicatricial  contraction 
present  in  the  great  majority. 

4.  Fever. — The  elevations  of  temperature  caused  by 
infection  due  to  gall-stones  are  characterised  by  their 
abruptness.  The  temperature  rises  rapidly,  attains  its 
maximum,  and  then,  with  almost  equal  speed,  returns 
to  the  normal.  Between  the  attacks  of  infection  the 
temperature  remains  approximately  normal.  When  the 
infection  is  limited  to,  or  chiefly  affects,  the  gall-bladder, 
there  is  a  rise  of  temperature  up  to  ioi°-i04°,  accord- 
ing to  the  severity  of  the  infection.  In  the  slighter 
cases  the  temperature  rises  to  101°,  and  some  local  ten- 
derness is  developed,  but  within  two  or  three  days  all 
returns  to  the  normal.  In  the  severer  cases  a  rigor 
may  occur,  and  the  infection  may  be  so  severe  that  an 
acute  cholecystitis,  or  a  phlegmonous  cholecystitis,  may 
develop,  and  the  plight  of  the  patient  is  serious  indeed. 

In  many  cases  it  is  found  that  the  elevation  of  tem- 
perature or  the  occurrence  of  a  rigor  precedes  the  on- 
set of  pain.  The  acute  inflammation  in  the  gall-blad- 
der causes  a  rise  to  101°  or  higher,  and  is  responsible 
for  the  increased  effusion  from  the  mucosa  into  the 
gall-bladder;  and  it  is  this  which,  in  its  turn,  causes 
an  increase  of  tension  and  pain.  If  there  are  repeated 
attacks  of  cholecystitis,  the  temperature  does  not  re- 
main high  in  the  intervals,  but  rises  abruptly  at  each 
fresh  infection  and  soon  returns  to  the  normal.  If, 
however,  suppuration  occurs,  then  a  continuous  eleva- 
tion of  temperature  to  101°  or  102°  may  be  found. 


Fever  133 

Budd,  Schmidt,  Schiippel,  and  others  of  the  eariier 
writers  spoke  of  the  rigors  and  the  elevations  of  tem- 
perature as  "nervous"  in  origin  and  as  comparable 
with  the  rigors  of  urethral  fe\'er.  We  now  recognise 
that  both  this  fever  and  urethral  fever  are  bacterial 
in  origin,  the  result  of  an  undoubted  infection. 

When  there  is  stone  in  the  common  duct,  an  attack 
of  colic  is  followed  by  or  accompanies  a  rigor,  some- 
times severe,  sometimes  in  miniature.  The  tempera- 
ture again  rises  abruptly  and  again  quickly  descends. 
Between  such  attacks  the  temperature  may  be  nor- 
mal. 

A  temperature  chart,  shewing  these  attacks  of  in- 
fection, represented  by  an  abrupt,  peak-like  elevation 
with  the  normal  interspace  is  most  characteristic.  In 
describing  the  chart  to  students  I  am  accustomed  to 
calling  it  the  "steeple"  chart. 

The  occurrence  of  these  angular  elevations  in  the 
chart  recording  the  temperature  is  quite  pathognomonic 
of  gall-stone  disease.  I  am  not  aware  that  any  other 
charts,  except  perhaps  those  of  malarial  fever,  resemble 
these  to  a  degree  which  can  cause  a  doubt  in  the  mind 
of  the  surgeon.  Murphy  speaks  of  the  "temperature 
angle  of  cholangic  infections."  He  writes  (Med.  News, 
vol.  I,  1903,  p.  830)  :  "The  temperature  in  an  hour  will 
rise  to  104°  or  105°,  remain  stationary  for  a  few  hours, 
and  then  drop  as  suddenly  to  normal,  and  remain  nor- 
mal for  hours,  days,  or  even  weeks,  when  it  will  go 
through  the  same  rapid  variation  and  continue  to  repeat 
itself  at  irregular  intervals."  And  again:  "These  tem- 
perature changes  are  so  characteristic  that  I  have  given 


134    Symptoms  and  Signs  of  Gall-stone  Disease 

them  the  name  of  '  the  temperature  angle  of  cholangic 
infection.'  " 

These  characteristic  charts  are  reproduced  by  both 
Charcot  and  Naunyn,  though  their  perfectly  charac- 
teristic appearance  does  not  seem  to  have  been  remarked 
by  either.  Charcot,  in  his  original  account  of  "inter- 
mittent hepatic  fever,"  depicted  a  most  excellent 
"steeple"  chart,  a  part  of  which  is  reproduced  in  Fig.  46. 

In  later  stages  of  acute  disease,  when  the  intense 
infection  has  spread  throughout  the  finer  bile  channels 
in  the  liver,  the  temperature  may  show  no  remissions, 
but  remain  persistently  high.  In  such  cases  the  tem- 
perature may  range  from  103°  to  105°,  and  never  return 
to  the  normal.  As  a  rule,  fever  of  this  type  follows 
the  intermittent  fever  previously  described,  and  is  a 
sign  of  a  more  generalised  and  more  intense  infection. 

5.  Tumour. — A  tumour  of  the  gall-bladder  in  chole- 
lithiasis occurs  as  a  result  of  a  block  in  the  cystic  duct, 
by  a  stone,  by  the  enlargement  of  a  lymphatic  gland, 
or  by  torsion  or  flexion  at  the  neck  of  the  gall-bladder. 
It  occurs  also  w^hen  there  is  obstruction  to  the  common 
duct  by  enlargement,  simple  or  malignant,  of  the  head 
of  the  pancreas.  In  rare  cases  an  enlargement  of  the 
gall-bladder,  due  solely  to  its  being  crowded  with  stones, 
may  be  recognised  on  palpation  of  the  abdomen.  Sev- 
eral observers  have  been  able  to  grasp  the  gall-bladder 
and  to  feel  the  stones  therein  rubbing  together.  Petit, 
in  1743,  speaks  of  a  gall-bladder  feeling  "like  a  haj  of 
nuts"  when  distended  with  stones.  Lessdorf  was  able 
to  invaginate  his  hand  within  the  abdomen  through 
the  neck  of  a  large   umbilical   hernia   and   to   grasp   a 


Tumour  135 

stone-containing  gall-bladder.  I  have  once,  in  the  lax 
and  pendulous  abdomen  of  a  multipara,  been  able  to 
feel  a  gall-bladder  filled  with  stones,  to  recognise  that 
its  shape  was  hour-glass,  and  at  the  operation,  a  few 
days  later,  to  verify  my  observation. 

When  a  stone  is  impacted  in  the  pelvis  of  the  gall- 
bladder or  in  the  cystic  duct,  the  gall-bladder  distends 
behind  the  block.  The  fluid  contained  within  it  may 
at  first  be  deeply  tinged  with  bile,  but  soon  all  trace 
of  colouring  matter  disappears,  and  a  condition  of 
hydrops  exists  in  which  a  clear  or  opalescent  mucoid 
fluid  is  found.  If  there  is  infection,  the  fluid  becomes 
purulent  and  a  condition  of  empyema  of  the  gall-bladder 
is  recognised. 

A  distended  gall-bladder  which  contains  bile  is  due 
to  pressure  upon  the  common  duct  by  growths  or  chronic 
inflammation  in  the  pancreas,  or  by  growths  originating 
in  closely  adjacent  structures. 

A  tum.our  of  the  gall-bladder  may  be  due  to  malig- 
nant disease,  which,  in  the  majority  of  instances,  is  a 
late  result  of  gall-stone  irritation. 

The  tumour  formed  by  the  enlarged  gall-bladder  is 
generally  easy  to  recognise.  It  forms  a  prominence 
visible  on  inspection  of  the  abdomen  in  some  instances, 
and  in  many  is  readily  appreciated  as  lying  just  beneath 
the  abdominal  wall.  It  is  generally  pear-shaped  or 
like  a  banana  in  form,  smooth  in  contour,  and  may 
sometimes  possess  a  range  of  considerable  mobility, 
swinging  pendulum-like  from  side  to  side,  reaching, 
in  some  cases,  as  far  as  the  left  hypochondrium.  As 
a  rule,  the  swelling  is  tender,  and  a  feeling  of  nausea 


136    Symptoms  and  Signs  of  Gall-stone  Disease 

is  excited  upon  handling  it.  Immediately  above  the 
tumour  can  be  felt  the  edge  of  the  liver.  The  colon 
on  inflation  is  found  to  lie  below  it,  or,  rarely,  beneath 
it,  though  in  one  case  I  have  found  the  colon  to  be 
adherent  to  the  edge  of  the  liver  above  the  gall-bladder, 
so  that  on  inflation  the  swelling  was  recognised  as  being 
below  the  colon  and  made  less  easily  palpable.  Law- 
son  Tait  and  Liicke  have  described  cases  in  which 
the  small  intestine  was  adherent  in  this  position.  A 
large  mass  of  thick  omentum  over  the  gall-bladder  may 
blur  the  outline  of  the  tumour,  so  that  its  character- 
istic shape  is  not  recognisable.  Inflation  of  the  stomach 
is  often  a  useful  aid  to  diagnosis.  A  gall-bladder  tumour 
in  this  way  is  displaced  to  the  right  and  a  little  upward, 
and,  as  Naunyn  has  pointed  out,  it  may  become  pushed 
against  the  abdominal  wall  and  therefore  be  more  dis- 
tinctly palpable.  The  attachments  of  the  tumour  to 
the  liver  may  be  recognised  by  their  simultaneous  de- 
scent when  the  patient  breathes  deeply.  The  tumour 
cannot  be  held  down  during  respiration,  but  moves 
upward  and  under  the  hand  at  precisely  the  moment 
when  the  ascent  of  the  liver  begins.  Other  tumours, 
those,  for  example,  of  the  kidney,  or  stomach,  or  colon, 
or  omentum,  can  be  held  downwards  when  grasped  at 
the  end  of  a  full  inspiration.  In  some  cases  the  extent 
of  the  projection  of  a  gall-bladder  beyond  the  margin  of 
the  liver  is  no  criterion  as  to  the  size  of  the  gall-bladder 
or  as  to  its  capacity,  for  in  several  instances  where 
little  more  than  the  rounded  fundus  can  be  felt,  or  seen 
after  the  abdomen  is  opened,  there  may  be  a  consider- 
able dilatation  of  the  part  concealed  by  the  li\-er.  and  on 


Tumour  137 

aspiration  15  to  20  ounces  of  fluid  may  be  removed. 
In  many  cases  of  old-standing  cholelithiasis,  the  lower 
edge  of  the  liver  is  dragged  down  to  the  right  and  in 
front  of  the  gall-bladder  into  a  tongue-shaped  lobe 
which  is  generally  known  as  the  "linguiform  lobe  of 
Riedel." 

Further  reference  to  the  characters  of  a  distended 
gall-bladder  will  be  made  in  discussing  the  condition 
of  "hydrops  " 

A  tumour  found  in  the  neighbourhood  of  the  gall- 
bladder may  be  caused  by  an  adhesion  of  an  enlarged 
gall-bladder  to  the  abdominal  wall.  Stones  therein 
contained  may  then  ulcerate  through  into  the  abdominal 
wall.  In  such  cases  a  tumour  which  closely  resembles, 
in  its  physical  characters,  a  growth  in  the  muscles  of 
the  abdominal  wall  may  form.  The  tumour  is  hard, 
rounded,  smooth,  and  fixed,  but  it  is  not  adherent  to 
the  skin.  ]\Iordret  and  i\Iichaux  record  examples  of 
this  kind.  (Bull,  et  Mem.  Soc.  de  Chir.,  vol.  29,  p. 
1189.) 

Enlargement  of  the  liver  may  be  noticed  in  many 
cases  where  gall-stones  are  passing  down  the  ducts  or 
attempting  to  do  so.  As  a  rule,  in  all  gall-stone  attacks 
the  liver  enlarges  and  becomes  tender  In  some  cases 
the  increase  in  size  is  remarkable  Naunyn  remarks: 
' '  I  have  seen  a  previously  normal  liver  examined  by 
myself  so  to  increase  in  size  in  the  course  of  a  few  days 
as  to  extend  as  far  as  the  hypogastrium  as  a  quite  mas- 
sive tumour,  and  this  not  by  any  means  only  in  cases 
with  severe  colic,  but  even  in  those  with  slight  pain 
and  hardly  perceptible  jaundice."     The  recession  of  the 


138     Symptoms  and  Signs  of  Gall-stone  Disease 

hepatic  enlargement  is  generally  rapid  and  complete 
unless  further  attacks  follow  or  there  is  abscess  or 
malignant  disease. 


THE  DIFFERENTIAL  DIAGNOSIS   OF   GALL-STONE   DISEASE. 

To  discriminate  between  gall-stone  disease  and  many 
other  affections  producing  pain,  localised  or  general, 
within  the  abdomen,  and  radiating  to  the  chest  and 
back,  with  vomiting  and  perhaps  collapse,  is  often  a 
matter  of  difficulty,  and  is  sometimes  impossible  of 
achievement.  Nevertheless,  it  is  a  fact  that  the  diag- 
nosis of  gall-stones  is  often  made  readily  and  w4th  cer- 
tainty. This  has  been  more  apparent  during  recent 
years  since  the  earliest  stages  of  the  disease  have  been 
recognised  and  dealt  with  by  the  surgeon.  The  "pro- 
dromal stage"  of  cholelithiasis  described  by  Kraus, 
upon  which  Naunyn  threw  doubts,  is  not  the  stage,  as 
he  thought,  of  the  formation  of  gall-stones;  it  is  the 
stage  in  which  gall-stones  insidiously  formed  are  begin- 
ning to  cause  discomfort.  Nothing  is  more  certain 
than  this,  that  in  the  majority  of  cases  of  cholelithiasis 
the  symptoms  in  the  earlier  stages  are  not  ascribed 
by  the  patient  to  the  presence  of  gall-stones,  but  are 
referred  to  "spasms,"  "indigestion,"  or  other  equally 
indefinite  diseases. 

The  various  diseases  with  which  gall-stone  disease 
may  be  confounded  are  gastric  ulcer,  or,  rarely,  car- 
cinoma; duodenal  ulcer;  appendicitis  in  its  varied 
forms;  diseases  of  the  right  kidney,  more  especially 
calculus,    or    that    intermittent    kinking    of    the    ureter 


1 


Differential  Diagnosis  of  Gall-stone  Disease    139 

or  of  the  vessels  of  the  kidney  which  causes  Dittel's 
crises ;  lead  colic ;  affections  of  the  right  pleura  or  lung, 
and  the  gastric  crises  of  locomotor  ataxia.  Among  rarer 
conditions  may  be  mentioned  aneurysm  of  the  hepatic 
artery,  which  was  first  noted  by  Riedel,  and  has  since 
been  observed  by  Kehr,  and  a  diffuse  syphilitic  hepa- 
titis, both  of  which  have  given  rise  to  grave  difficulties 
in  diagnosis. 


CHAPTER  V. 

THE  SPECIAL  SYMPTOMS  IN  GALL-STONE  DISEASE. 

In  discussing  the  symptoms  of  gall-stone  disease 
Naunyn  has  described  two  forms  of  cholelithiasis — 
"regular  cholelithiasis"  and  "irregular  cholelithiasis." 
Of  regular  cholelithiasis  he  writes:  "This  then  is  the 
regular  course  of  cholelithiasis  that  the  concretions 
traverse  the  bile-duct  and  enter  the  duodenum  without 
doing  any  considerable  amount  of  permanent  damage." 
The  use  of  the  term  "regular,"  therefore,  is  held  as 
applying  to  that  form  of  the  disease  which  manifests 
itself  in  the  classic  gall-stone  "attacks."  It  is  an  un- 
fortunate term  if  it  suggests  that  such  attacks  are  the 
common  or  even  a  usual  manifestation  of  the  presence 
of  gall-stones.  It  is  certainly  only  in  a  small  propor- 
tion of  the  cases  that  come  to  operation  that  regular 
cholelithiasis  is  seen.  Gall-stones  arouse  symptoms  that 
are  dealt  w4th  by  operation  in  a  very  large  number  of 
cases  when  nothing  in  the  nature  of  a  "regular"  chole- 
lithiasis has  been  observed.  Naunyn 's  work  was,  of 
course,  based  mainly  upon  clinical  and  postmortem 
investigation,  the  ripe  harvest  of  operative  experience 
was  only  then  being  sown. 

In  discussing  the  symptoms  and  in  describing  the 
pathology  of  the  various  forms  of  gall-stone  disease 
it  will,  therefore,  be  desirable  to  consider,   firstly,   the 

140 


Special  Symptoms  in  Gall-stone  Disease        141 

signs  and  symptoms  which  result  in  "regular  chole- 
lithiasis."— that  is,  in  those  attacks  in  which  a  stone 
leaves  the  gall-bladder,  traverses  the  cystic  and  com- 
mon ducts,  and  finally  escapes  into  the  duodenum, — 
and,  secondly,  the  signs  and  symptoms  which  are  caused 
by  the  arrest  of  the  stone  in  any  part  of  this  course. 

First. — The  symptoms  due  to  the  passage  of  a  stone 
from  the  gall-bladder  to  the  duodenum. 

As  a  rule,  the  patient  will  have  had  previous  warning 
that  there  is  something  wrong  in  the  abdomen,  and 
a  diagnosis  of  gall-stones  confined  to  the  gall-bladder 
ma}"  have  been  made.  In  an  "attack"  of  the  kind 
now  to  be  described  the  pain  generally  commences 
with  absolute  suddenness.  There  are  many  conditions 
which,  by  individual  patients,  are  recognised  as  being 
inciting  factors,  such,  for  example,  as  the  onset  of  men- 
struation, the  ingestion  of  an  unduly  hearty  or  indi- 
gestible meal,  an  attack  of  diarrhoea,  due  to  irregular 
feeding  or  perhaps  to  the  taking  of  an  aperient,  and 
so  forth.  In  a  certain,  perhaps  not  inconsiderable, 
number  of  patients  a  recent  attack,  one  among  a  series, 
of  appendicitis  may  have  been  experienced.  Some 
patients  are  able  to  predict  the  onset  of  an  attack  by 
the  feeling  of  unusual  heartiness  and  vigour  which 
they  experience.  In  the  days  preceding  an  attack 
there  may  be  a  better  appetite  and  food  may,  there- 
fore, be  taken  in  larger  quantity.  This  is  probably 
due  to  the  fact,  to  which  Ewald  and  others  have  drawn 
attention,  that  hyperchlorhydria  often  precedes  an 
attack  for  two  or  three  days.  The  pain  usually  comes 
late  in  the  day,  in  the  afternoon  or  evening,  or,  espe- 


142        Special  Symptoms  in  Gall-stone  Disease 

cially  in  the  first  attack,  as  Naunyn  has  said,  at  mid- 
night. It  increases  rapidly,  becomes  spasmodic  in 
character,  and  radiates  to  the  shoulders,  to  the  epigas- 
trium, to  the  chest  and  neck.  The  pain,  when  attain- 
ing its  height,  is  generally  said  to  cause  the  patient  to 
be  "doubled  up,"  or  to  roll  in  agony  upon  the  floor. 
It  induces  collapse,  a  feeling  of  nausea,  and  vomiting. 
The  pain  may  last  continually,  without  even  the  small- 
est intermission,  for  hours,  or  it  may  be  lulled  for  a 
few  moments,  only  to  be  renewed  with  equal  severity. 
When  most  intense,  it  seems  to  prevent  the  patient 
from  taking  a  deep  breath,  and  the  open  hand  is  held 
protectingly  over  the  hepatic  area,  forming,  as  it  were, 
a  splint.  The  vomiting,  which  soon  follows,  seems  to 
give  some  measure  of  relief;  bile  is  often,  indeed  as  a 
rule,  present  in  the  vomit.  There  may  be  a  feeling 
of  intense  depression,  and  the  patient  may  shiver  with 
the  cold.  The  occurrence  of  a  rigor  with  a  tempera- 
ture of  103°  or  104°  is  rare,  though  not  unknown. 
Naunyn  says  "very  commonly  severe  rigors  accompany, 
the  colic  attacks,"  a  statement  which  is  not  in  accord- 
ance with  the  observation  of  many  authors.  "Severe" 
rigors  are  almost  unknown  in  the  classical  "gall-stone 
attack,"  though  slight  shivering  followed  by  sweating 
is  commonly  observed.  In  some  instances  tetany  may 
be  seen.  In  one  patient,  a  lady  of  twenty-seven,  who 
suffered  for  two  years  from  gall-stones,  the  tetanic 
seizures  caused  even  greater  suffering  than  the  colic. 
The  pain  may  persist  for  hours  or  even  days,  and  may 
end  gradually,  or  with  as  marked  a  suddenness  as  oc- 
curred at  the  onset.     A  feeling  of  stiffness  or  soreness 


Special  Symptoms  in  Gall-stone  Disease        143 

is  left  for  days,  the  patient  often  saying  that  the  side 
"feels  bruised."  During  the  pain  or  soon  afterwards 
jaundice  is  noticed,  with  the  appearance  of  bile  in  the 
urine  and  the  absence  of  bile  in  the  motions.  Bile 
is  often  noticed  in  the  urine  before  a  tinge  of  yellow- 
ness is  seen  in  the  conjunctivas.  The  clay-coloured 
appearance  of  the  stools  is  not  invariable;  it  may  be 
absent  even  when  jaundice  is  present  in  the  skin,  and 
the  urine  shews  the  colour  of  bile.  There  is  not  seldom 
a  troublesome  itching  of  the  skin,  which  appears  before 
the  jaundice,  and  may  remain  when  the  jaundice  has 
quite  cleared  away,  or  more  commonly  may  disappear 
some  days  before  the  jaundice.  During  the  attack 
the  pulse  rate  is  said  by  Naunyn  to  be  slow.  This 
is  not  in  accordance  with  my  own  experience.  I  have 
not  found  any  reduction  in  the  pulse  rate  in  jaundice 
unless  a  degree  of  chronic  pancreatitis  is  present.  Con- 
stipation is  present  after  and  during  the  attack,  appe- 
tite is  lost,  and  there  is  a  feeling  of  general  ill-health. 
The  tongue  is  foul  and  thirst  is  often  unquenchable. 
The  liver  and  the  spleen  are  generally  enlarged,  and 
the  former  is  very  tender.  The  gall-stone,  which  is 
the  cause,  in  its  transit  through  the  duct,  of  all  these 
symptoms,  is  passed  into  the  duodenum  and  may  be 
recovered  in  the  motions.  "  In  regular  cholelithiasis," 
Naunyn  writes,  "the  stones  are  passed  in  the  motions. 
They  are  often  sought  for  in  vain,  but  such  failures 
are  usually  due  to  the  examination  of  the  stools  being 
not  carried  out  continuously  or  over  a  long  enough 
period."  The  reasons  for  the  want  of  discovery  of 
stones  in  the  fasces  are  thus  given  by  Naunyn: 


144        Special  Symptoms  in  Gall-stone  Disease 

"i.  The  stone,  after  having  been  driven  into  the 
neck  of  the  gall-bladder,  may  have  fallen  back 
into  the  bladder.  This  can  hardly  be  a  common 
event. 

"2.  The  stone  may  have  remained  fixed,  whereas  the 
patency  of  the  duct  has  been  restored. 

"3.  The  concretion  may  have  disintegrated  in  the 
bowel." 

It  is  not  improbable  that  the  condition  first  men- 
tioned is,  as  a  fact,  distinctly  a  common  event,  if  not 
the  most  common  event,  in  patients  who  harbour  stones 
in  the  gall-bladder.  An  attack  of  this  kind  may  be 
the  first  and  the  only  attack  from  which  a  patient  suf- 
fers. Such  an  event  is,  however,  extremely  rare.  Other 
attacks  follow  with  greater  or  less  frequency,  and  with 
more  or  less  modification  other  complications  may 
develop,  and  "irregular"  cholelithiasis  in  any  of  its 
varied  forms  may  be  seen. 

The  symptoms  detailed  above  are  those  which  are 
due  to  the  passage  of  a  gall-stone  from  the  gall-bladder 
to  the  duodenum.  In  the  case  of  patients  operated 
upon  for  gall-stones  by  the  surgeon  a  history  which 
suggests  that  such  a  transit  has  occurred  is  decidedly 
rare.  In  my  own  experience  it  is  present  in  less  than 
20  per  cent.  The  great  majority  of  the  operations  prac- 
tised to-day  are  advised  because  recognition  is  made  of 
the  nature  of  the  disease  in  an  earlier  stage  than  this. 

The  presence  of  albumin  in  the  urine  during  and 
for  some  time  after  an  attack  has  been  not  seldom  ob- 
served. It  is,  however,  by  no  means  constant  and 
has  no  diagnostic  significance. 


Stones  in   the  Gall-bladder  145 

Second. — Under  this  heading  are  to  be  described  the 
symptoms  which  are  caused  by  the  arrest,  temporary 
or  permanent,  of  a  stone,  at  any  part  of  its  course 
from  the  gall-bladder  to  the  duodenum,  and,  in  brief, 
the  pathological  changes  which  are  thereby  invoked. 
It  will  be  convenient  to  consider  the  subjects  in  the 
following  order: 

(A)  Stones  in  the  gall-bladder. 

(B)  "  "       cystic  duct. 

(C)  "  "       hepatic  duct. 

(D)  "  "       common  duct,  including  the  ampulla 

of  Vater. 

(A)  STONES  IN  THE  GALL-BLADDER. 

In  all  cases  of  cholelithiasis  it  is  the  inflammation 
which  the  stones  arouse,  rather  than  the  stones  them- 
selves, which  is  responsible  for  the  production  of  the 
chief  symptoms.  In  a  large  number  of  cases  gall-stones 
are  found  at  a  postmortem  examination  when  no  evi- 
dence of  their  existence  has  been  observed  during  life. 
Quincke,  for  example,  writes:  "In  many,  in  fact  in  the 
majority,  of  the  cases  of  concretions  within  the  gall- 
bladder or  the  bile  passages,  all  symptoms  are  absent 
and  the  condition  is  only  discovered  at  autopsy."  This 
statement  and  all  the  similar  ones  to  be  found  in  text- 
books of  medicine  are  probably  exaggerated.  They 
do  not  take  into  account  the  facts,  made  clear  by  the 
experience  of  the  surgeons,  that  what  were  formerly 
considered  the  typical  symptoms  and  signs  of  gall-stones 
are  present  in  very  few  cases  of  cholelithiasis.  The 
commonest    symptom  of   gall-stones  is  not   referred  to 


146       Special  Symptoms  in  Gall-stone  Disease 

the  biliary  passages  at  all.  It  is  "indigestion"  in  the 
patient's  vocabulary.  Riedel,  in  a  recent  paper,  states 
that  of  100  cases  of  epigastric  colic  ("stomach  cramp"), 
97  are  due  to  gall-stones.  In  a  patient  who  has  suffered 
for  years  from  "gastric  neuralgia"  the  discovery  of  gall- 
stones at  the  autopsy  is  not  always  held  to  explain  the 
symptoms. 

It  will,  however,  be  allowed  by  all  surgeons  that  the 
presence  of  stones  in  the  gall-bladder  does  not  necessa- 
rily cause  symptoms,  for  gall-stones  are  occasionally 
found  during  the  performance  of  other  abdominal 
operations,  when  a  close  enquiry  subsequently  fails  to 
elicit  any  history  of  symptoms.  Something  more  than 
the  mere  presence  of  the  stones  is,  therefore,  necessary  to 
arouse  the  knowledge  of  their  existence.    This  may  be: 

1.  A  sudden  movement  among  the  stones,  a  disturb- 
ance or  disarrangement  of  them,  however  excited. 

2.  The  impaction  of  a  stone  or  stones  in  the  cystic 
or  common  or  hepatic  ducts. 

3.  Infection  of  the  gall-bladder  or  any  part  of  the 
bile- tract. 

The  bacillus  coli  is  the  organism  most  often  found, 
but  in  cases  of  suppuration  the  staphylococcus  pyogenes 
aureus  or  albus  may  also  be  present.  Ehret  and  Stolz 
(Berl.  klin.  Woch.,  1902),  in  order  to  discover  the  cause 
of  the  sudden  onset  of  symptoms  of  an  acute  infective 
character  in  cases  of  cholelithiasis,  fed  dogs,  into  whose 
gall-bladders  sterilised  glass  balls  had  lain  for  three 
months  without  causing  symptoms,  upon  decomposing 
meats.     An  acute  enteritis  was  set  up  and  was  followed 


Stones  in   the  Gall-bladder  147 

by  a  purulent  cholecystitis.  The  infection  in  these 
cases  was  an  ascending  one  from  the  duodenum.  Any 
irritating  or  decomposing  food  may  not  only  introduce 
fresh  organisms  into  the  intestine :  it  may  also  tend 
to  increase  the  activity  of  any  that  may  be  already 
there.  When  stones  are  contained  within  the  gall- 
bladder, the  symptoms  which  they  cause  are  therefore, 
due  to  one  or  other  or  all  of  the  causes  above  men- 
tioned. It  is  probable  that  disarrangement  excites 
infection,  the  mere  moving  of  the  calculi,  apart  from 
some  traumatism  to  the  gall-bladder  and  subsequent 
infection,  being  unlikely  to  excite  any  symptom.  The 
symptoms  therefore  of  gall-stones  in  the  gall-bladder 
are  those  of  cholecystitis,  and  they  vary  in  severity 
precisely  in  accordance  with  the  intensity  and  virulence 
of  the  infection. 

In  acute  cholecystitis  there  are  pain,  nausea  and 
vomiting,  collapse,  great  local  tenderness,  and  perhaps 
swelling  and  fever.  The  pain  comes  on  suddenly  and 
is  of  great  severity;  it  affects  the  whole  of  the  right 
hypochondrium,  radiates  to  the  back  and  over  the 
front  of  the  abdomen  and  chest.  It  is  of  such  intensity 
in  the  more  acute  forms  that  the  patient  may  roll  in 
agony  on  the  floor.  His  face  is  then  anxious  and  drawn 
and  ashen-coloured,  he  sweats  profusely  and  is  cold, 
and  his  pulse  may  be  extremely  feeble.  There  are  nausea 
and  repeated  vomiting,  and  bile  is  not  seldom  present 
in  the  vomit.  The  gall-bladder  may  be  palpable,  but 
is  more  often  protected  by  a  rigid  covering  of  muscle, 
made  tense  by  the  irritation  and  inflammation  beneath. 
Jaundice  is  but  rarely  present,  and  is  then  due  to  an 


148        Special  Symptoms  in  Gall-stone  Disease 

extension  of  the  inflammation  down  the  cystic  to  the 
common  duct.  It  is  probably  not  present  in  more 
than  one  or  two  per  cent,  of  cases  of  cholecystitis.  The 
symptom  to  which  many  patients  refer  is  a  stiffness 
or  soreness  or  sense  of  bruising  in  and  about  the  right 
hypochondrium  for  two  or  three  days  after  an  acute 
attack  of  pain.  This,  which  is  similar  to  that  felt  before 
a  subacute  perforation  of  an  ulcer  of  the  stomach,  is 
probably  due  to  a  localised  but  subdued  form  of  peri- 
tonitis. A  patient  suffering  from  this  will  hold  the 
hand  firmly  pressed  to  the  side  when  walking  up  or 
down  stairs  or  in  attempting  to  bend.  In  those  cases 
where  a  stone  is  temporarily  impacted  in  the  cystic  duct, 
the  symptoms  are  always  more  severe.  The  tempera- 
ture is  higher,  even  to  104°,  and  there  may  be  a  rigor. 
The  temperature  chart  shews  then  the  characteristic 
"steeple"  form — a  sudden  rise  to  a  great  height  followed 
by  a  fall  to  the  normal.  There  is  more  serious  depres- 
sion and  the  vomiting  is  more  exhausting.  The  patient's 
condition  is  indeed  serious.  In  some  such  instances 
the  infection  may  be  so  intense  as  to  lead  to  ulceration 
or  gangrene  of  the  gall-bladder  or  to  empyema  If  the 
stone  drop  back  into  the  gall-bladder,  the  infection 
generally  subsides  rapidly,  and  in  a  week,  or  rather 
longer,  the  condition  of  things  may  return  to  the  nor- 
mal. After  a  respite  all  the  symptoms  may  be  repeated 
in  an  attack  of  mild  or  great  severity.  After  one  or 
more  such  attacks  a  condition  of  chronic  cholecystitis 
persists,  and  the  gall-bladder  may  present  a  variety 
of  aberrations  from  the  normal.  It  may  be  small, 
shrunken,  or  shrivelled,  with  thin  fibrous  walls  and  a 


i 


Stones  in  the  Gall-bladder  149 

cavity  that  is  barely  to  be  recognised.  In  one  such 
example  it  was  at  first  thought  that  the  gall-bladder 
was  absent,  and  it  was  only  after  a  tedious  and  pro- 
longed postmortem  dissection  that  an  insignificant 
remnant  of  it  was  laid  bare.  In  other  cases  a  thick  gall- 
bladder, intimately  adherent  to  omentum,  duodenum, 
or  colon,  may  be  found,  and  in  the  cavity  of  this  a  small 
quantity  of  thick  viscid  mucus.  Or  in  still  others  the 
gall-bladder  may  be  a  little  thickened  and  adherent, 
its  walls  are  opaque,  white  and  stiffened,  but  bile  may 
still  enter  the  bladder,  as  a  reservoir. 

When  chronic  cholecystitis  is  present,  there  is  almost 
always  a  constant  dull  aching,  sometimes  hardly  per- 
ceptible, sometimes  of  severe  degree,  in  the  right  hypo- 
chondrium.  The  pain,  during  any  exacerbation  of  the 
inflammatory  process,  may  be  temporarily  more  acute. 
It  is  in  this  form  of  disease  that  the  differential  diag- 
nosis is  most  difficult.  The  symptoms  are  dull,  diffuse 
pain  of  the  type  mentioned;  a  feeling  of  fullness,  flatu- 
lence, or  distension  coming  on  during  a  meal,  often  after 
the  first  few  mouthfuls  have  been  swallowed,  occasional 
backache,  or  aching  in  the  shoulder  and  probably  con- 
stipation. In  the  symptoms  there  is,  it  will  be  seen, 
nothing  characteristic,  nothing  that  by  many  surgeons 
would  be  considered  even  suggestive  of  cholecystitis  or  of 
any  form  of  gall-stone  disease.  It  is  in  this  class  of  cases 
that  the  pressure  sign  is  of  the  greatest  help.  It  is 
the  inability  of  the  patient  to  take  a  full,  deep  inspira- 
tion when  the  surgeon  s  fingers  are  hooked  up  deep 
beneath  the  right  costal  arch,  below  the  hepatic  region. 
If  the  tips  of  the  fingers  be  "worked  in"  gradually  until 


150        Special  Symptoms  in  Gall-stone  Disease 

the  muscles  have  relaxed  and  the  liver  edge  can  be  felt, 
then,  as  soon  as  the  patient  takes  a  deep  breath,  the 
tender,  chronically  inflamed  gall-bladder  is  forced  down- 
wards against  the  fingers  and  the  inspiration  suddenly 
stops,  ending  in  a  deep  sighing  or  brisk  expiratory  effort. 
When  an  acute'  infection  leading  to  suppuration  occurs, 
it  is  generally  the  result  of  a  block  in  the  cystic  duct. 
Gall-stones  contained  within  the  gall-bladder  rarely 
cause  pressure  symptoms. 

The  following  case  of  death  from  pressure  of  gall- 
stones contained  in  the  gall-bladder  on  the  vena  porta  is 
recorded  by  A.  S.  Donkin  (Med.  Times,  1868,  vol.  2,  p.  396) : 

The  patient  was  a  man  aged  fifty-six.  On  April  4, 
1868,  he  had  a  hearty  supper  and  went  to  bed  in  his 
usual  health.  About  midnight  he  awoke  in  great  agony 
with  intense  pain  in  the  abdomen  and  vomiting  of  fluid 
deeply  tinged  with  bile.  The  pain  and  vomiting  con- 
tinued up  to  April  7  th,  when  nine  leeches  were  applied 
to  the  epigastrium  without  giving  relief.  On  April  8th 
the  pain  had  almost  subsided,  but  there  was  great  ten- 
derness over  the  region  of  the  stomach  and  the  vomiting 
was  incessant.  The  patient  gradually  became  worse 
and  died. 

Postmortem. — The  great  omentum  was  deeply  con- 
gested and  clots  of  dark  blood  were  scattered  between 
its  fold ;  the  lesser  omentum  was  less  highly  congested. 
The  mesentery  was  congested,  but  to  a  much  less  degree 
than  the  greater  omentum.  The  ascending  mesocolon 
was  extravasated  between  its  folds.  This  congestion 
extended  to  the  transverse  mesocolon,  but  to  a  much 
less  degree.  The  caecum  was  highly  congested,  while 
the  ascending  colon  opposite  the  seat  of  haemorrhage 
in  the  mesocolon  was  so  intense  that  it  presented  through- 


i 


Stones  in   the  Cystic  Duct  151 

out  on  its  mucous  surface  a  blackish  colour  from  en- 
gorgement of  its  minute  vessels  and  ecchymosis.  The 
stomach  contained  a  considerable  quantity  of  fluid;  the 
rest  of  the  intestines  were  quite  empty.  The  mucosa 
of  the  stomach  everywhere  showed  venous  congestion. 
Several  large  blackish  patches  were  observed  on  its 
surface  in  the  region  of  the  greater  and  lesser  curvatures. 
The  duodenum  was  highly  congested,  while  the  jejunum 
and  ileum  were  only  slightly  so.  The  liver  was  quite 
healthy.  The  gall-bladder  contained  three  large  calculi 
of  about  equal  size.  Together,  in  the  gall-bladder, 
they  formed  a  hard  solid  tumour  whose  posterior  ex- 
tremity rested  in  the  portal  fissure  over  the  portal  vein 
where  it  enters  the  liver,  thus  producing  mechanical 
compression  of  the  portal  vein  to  such  a  degree  as  to 
give  rise  to  all  the  phenomena  of  congestion  of  its  tribu- 
tary trunks  and  the  resulting  haemorrhages.  The  mus- 
cular coat  of  the  gall-bladder  was  atrophied,  with  thick- 
ening of  the  external  coat^  which  had  assumed  a  whitish 
colour. 

(B)  STONES  IN  THE  CYSTIC  DUCT. 
The  impaction  of  a  stone  in  the  cystic  duct  may  cause 
a   great   variety   of  results   in   the   gall-bladder.     These 
mav  be  enumerated  as  follows : 


(a)   Dilatation  of  the  gall-bladder . 


(6)  Acute  cholecystitis 


simple  hydrops, 

empvema. 
f  catarrhal, 
I  suppurative, 
I  gangrenous,  or 
I  phlegmonous. 


(c)  Sclerosis  of  the  gall-bladder. 

(d)  Calcification  of  the  gall-bladder. 


The  frequency  of  this  impaction  has  been  very  vari- 


152        Special  Symptoms  in  Gall-stone  Disease 

ously  estimated  by  different  writers.  Langenbuch  found 
stones  in  the  cystic  duct  in  one-third  of  the  cases  upon 
which  he  operated,  Riedel  in  two-thirds.  Schlott,  bas- 
ing his  figures  upon  a  series  of  postmortem  observations 
at  Basle  and  at  Erlangen,  found  stones  in  this  duct  in 
only  5.5  per  cent,  of  cases  of  cholelithiasis. 

(a)  Dilatation  of  the  Gall-bladder. — When  a  stone 
becomes  impacted  in  the  pelvis  of  the  gall-bladder  or 
in  the  cystic  duct,  there  is  a  rapid  distension  of  the 
gall-bladder  behind  the  obstruction.  At  the  first  the 
fluid  therein  contained  consists  of  bile-stained  mucus, 
but  as  the  obstruction  becomes  chronic  the  bile  is  ab- 
sorbed and  at  last  disappears  entirely.  The  fluid  then 
consists  only  of  mucus,  which  may  be  clear,  turbid,  or 
opalescent;  it  is  generally  alkaline  in  reaction  and  con- 
tains albumin.  I  have  found  it  sterile  in  old-standing 
cases.  In  recent  cases  the  bacilus  coli  is  generally 
present.  In  both  crystals  of  cholesterin  are  seen.  The 
overfull  gall-bladder,  due  to  obstruction  of  the  cystic 
duct,  never  contains  bile  alone.  When  the  gall-bladder 
is  tightly  distended  and  contains  bile,  there  is  almost 
always  an  obstruction  of  the  common  duct,  due  to 
other  causes  than  gall-stones.  The  distended  gall-blad- 
der soon  becomes  palpable  and  projects  from  beneath 
the  edge  of  the  liver.  It  may  reach  an  enormous  size, 
and  in  a  few  examples,  recorded  by  Lawson  Tait  and 
others,  the  swelling  has  been  mistaken  for  an  ovarian 
cyst.  The  wall  of  the  gall-bladder  is  generally  thin,  in 
proportion  to  the  quantity  of  fluid,  but  in  some  instances 
there  may  be  an  abundant  deposit  of  fibrous  tissue  and 
the   cyst  wall   may   be   grossly   thickened.     The   lining 


Dilatation  of  the  Gall-bladder 


153 


Fig.  40. — A  dilated  and  thickened  gall-bladder  containing  seven 
large  gall-stones,  one  of  which,  nearly  one  inch  in  diameter,  is  tightly 
impacted  in  its  cervix  and  completely  obstructs  the  passage  into  the 
cystic  duct.  The  patient,  a  gentleman  sixty  years  old,  died  with  a 
strangulated  hernia  (Royal  College  of  Surgeons'  Mtiseum,  No.  2815). 


154        Special  Symptoms  in  Gall-stone  Disease 

membrane  of  the  gall-bladder  loses  its  normal  reticula- 
tion and  becomes  rough,  coarsely  granular,  and  sodden 
in  appearance. 

A  condition  of  hydrops  may  result  from  any  form 
of  obstruction  to  the  cystic  duct;  as,  for  example, 
stricture  due  to  an  old  ulceration  caused  by  gall-stones, 
kink  ng,  enlargement  of  the  lymphatic  gland  outside 
the  sigmoid  curve,  or  growth  in  or  around  the  duct. 
In  a  few  cases  it  is  said  that  no  obstruction  of  the  duct 
has  been  found.  The  probability  is  that  in  such  in- 
stances there  has  been  a  sharp  kink  in  the  duct,  which, 
on  postmortem  examination,  has  been  undone  by  the 
removal  of  the  specimen.  The  cystic  gall-bladder  may 
enlarge  gradually  during  many  years,  or  may  remain 
unaltered.  A  very  remarkable  specimen  from  a  case 
of  Mr.  Skey's,  in  the  Museum  of  St.  Bartholomew's 
Hospital,  shews  an  enormously  distended  gall-bladder, 
a  part  of  which  w^as  found  as  the  content  of  the  sac 
of  a  femoral  hernia. 

The  gall-bladder  when  enlarged  forms  a  tumour  which 
is  pendulous  from  the  liver.  It  is  club-shaped,  the 
narrowed  end  being  the  stalk  of  attachment  to  the 
liver.  A  very  wide  range  of  movement  is  often  pos- 
sible, the  tumour  being  readily  made  to  present  well 
to  the  left  of  the  umbilicus. 

The  symptoms  caused  by  impaction  of  a  stone  in 
the  cystic  duct  are,  as  has  been  said,  very  acute  at  the 
time  of  the  occurrence,  but  if  the  obstruction  becomes 
chronic  and  a  hydrops  results,  the  symptoms  may  be 
singularly  few,  or  may  be  absent  altogether.  The  pain 
loses   its   colicky   character  very   early,   and   there   may 


Dilatation   of   the  Gall-bladder 


155 


Fig  41. — -A  gall-bladder,  measuring  5^  inches  in  length,  due  to  the 
impaction  of  a  calculus  in  the  cystic  duct.  In  its  cavity  lay  the  other 
four  calculi  shewn.  From  a  woman,  aged  twenty-eight,  who  had  suf- 
fered from  pain  in  the  right  hypochondrium  for  about  two  years, 
but  had  never  been  jaundiced.  She  made  a  rapid  recovery  (Royal 
College  of  Surgeons'  Museum,  No.  2830  f). 


156        Special  Symptoms  in  Gall-stone  Disease 

be  merely  a  dull  ache  or  a  trivial  sense  of  discomfort. 
The  tumour  is  not  necessarily  tender,  though  the  free 
handling  of  it  often  causes  a  feeling  of  nausea. 

The  tumour  is  to  be  recognised  as  being  caused  by 
the  gall-bladder ;  by  its  attachment  above  to  the  liver, 
the  lower  edge  of  the  liver  being  traceable  to  its  upper 
end ;  by  the  fact  that  it  does  not  fill  the  loin  and  cannot 
be  made  to  bulge  by  forward  pressure  in  the  flank;  by 
the  fact  that  inflation  of  the  colon  displaces  it  fonvards 
or  upwards,  and  not  downwards  (except  in  those  ex- 
tremely rare  cases  in  which  the  colon  is  adherent  at 
the  upper  part,  and  in  front,  of  the  gall-bladder),  and 
by  the  fact  that  inflation  of  the  stomach  causes  a 
displacement  of  the  tumour  slightly  to  the  right.  It 
is  thus  recognised  from  kidney  and  gastric  tumours. 
The  chief  difBcultv,  and  at  times  an  insurmountable 
one,  is  to  distinguish  the  lump  from  a  tumour,  hydatid 
or  malignant,  of  the  liver  near  its  free  edge.  The  per- 
fectly smooth  contour  and  the  absence  of  other  irregular 
nodules,  and  the  free  range  of  mobility  will  generally 
permit  an  accurate  discrimination  to  be  made. 

Hydrops  of  the  gall-bladder  results  when  infection  is 
absent  or  extremely  attenuated.  If  the  inflammation 
aroused  be  acute  and  the  infection  at  all  virulent,  empy- 
ema will  result.  The  clinical  conditions  associated  with 
the  empyema  xsivy  greatly  in  se\'erity,  and  are  in  direct 
proportion  to  the  intensity  of  the  infection.  In  the  more 
chronic  forms  the  symptoms  may  be  little  more  acute 
than  in  hydrops;  in  the  most  acute  they  are  so  grave 
that  a  fatal  result  mav   occur  within  a   few  da  vs.     In 


Dilatation  of  the  Gall-bladder  157 

all   cases   the  bacterium  coli   commune,  with  either  the 
staphylococcus  pyogenes  aureus  or  albus,  is  present. 

In  one  case,  illustrating  the  most  chronic  form  of  the 
disease,  the  patient  was  a  man,  aged  fifty-eight,  who  had 
suffered  for  twenty  years  from  "indigestion,"  and  full- 
ness and  distension  of  the  upper  abdomen  after  meals. 
Fifteen  days  before  the  operation  a  pain  had  suddenly 
been  felt  in  the  gall-bladder  region.  This  decreased  day 
by  day  for  several  days,  and  never  at  any  time  com- 
pelled the  patient  to  seek  rest  in  bed.  For  the  first  two 
days  there  was  a  temperature  ranging  as  high  as  100°. 
After  the  first  week  a  tumour  was  noticed  and  was  recog- 
nised by  the  medical  men  as  a  dilated  gall-bladder.  This 
increased  steadily  in  size,  and  at  length  was  approxi- 
mately equal  to  a  cocoanut.  It  was  slightly  tender  on 
pressure,  and  after  examination  the  side  "felt  stiff"  for 
two  or  three  hours.  At  the  operation  a  large,  densely 
thickened  gall-bladder  was  found  full  of  stones  and  pus, 
and  a  stone  was  impacted  in  the  cystic  duct.  The  gall- 
bladder and  cystic  duct  were  removed.  A  rather  more 
severe  form  is  illustrated  by  the  following  record: 

The  patient,  a  lady  of  forty-one,  had  suffered  for  sev- 
enteen years  from  gall-stone  attacks,  which  were  so 
recognised  by  her  husband,  a  medical  man.  Dieting  and 
medical  treatment  were  carried  out  with  alleviation  to 
symptoms,  except  on  about  six  occasions  during  seventeen 
years,  when  pain,  and  a  rigor  or  tenderness  in  the  region 
of  the  gall-bladder,  were  noticed.  There  had  never  been 
jaundice.  Three  weeks  before  I  saw  her  the  gall-bladder 
had  enlarged  to  the  size  of  a  lemon,  but  had  subsequently 
subsided  until  it  was  barely  as  large  as  a  hen's  egg.     A 


158        Special  Symptoms  in  Gall-stone  Disease 

rigor,  pain,  profound  collapse,  lasting  about  four  hours, 
had  occurred  at  the  onset  of  symptoms.  (Jn  examina- 
tion, the  day  before  operation,  there  was  marked  local 
tenderness — the  pressure  sign  being  readily  elicited — and 
some  enlargement  of  the  gall-bladder  was  recognisable. 
There  was  no  temperature,  no  pain,  when  the  patient  was 
resting,  and  food  was  taken  with  zest,  though  in  small 
quantities.  At  the  operation  an  hour-glass  gall-bladder, 
distended  with  pus  and  stones,  was  found.  The  cystic 
duct  was  blocked  by  a  stone  the  size  of  a  marble.  The 
gall-bladder  and  duct  were  removed  and  the  patient  made 
a  speedy  recovery. 

In  the  more  severe  forms  the  signs  of  acute  inflamma- 
tion in  the  gall-bladder  are  more  evident,  and  a  local 
peritonitis  is  clearly  present.  The  gall-bladder  is  exquis- 
itely tender,  and  its  outline  is  difficult  to  perceive,  owing 
to  an  intense  muscular  rigidity  which  protects  the  in- 
flamed area.  There  is  great  pain  in  the  whole  hepatic 
region,  which  is  made  worse  by  the  taking  of  a  deep 
breath  or  by  coughing  or  stooping.  There  is  generally 
a  marked  rise  of  temperature,  to  103°  or  104°,  and  a 
rigor  is  commonly  observed.  In  cases  of  this  type  the 
gall-bladder  becomes  very  intimately  adherent  to  sur- 
rounding structures,  to  the  colon,  the  duodenum,  or  the 
abdominal  wall,  and  if  ulceration  be  present  a  fistula 
may  form.  In  a  certain,  fortunately  small,  proportion 
of  cases,  rupture  of  the  gall-bladder  may  occur  without 
the  formation  of  protective  adhesions,  and  the  perfora- 
tion then  occurs  into  the  general  peritoneal  cavity.  If 
the  ulceration  extend  deeply  from  the  gall-bladder  into 
the  liver,  or  into  a  mass  of  adhesions,  a  cavity  may  form 
in  the  substance  of  the  liver,  or  in  the  centre  of  a  tough 


Dilatation  of  the  Gall-bladder  159 

fibrous  covering,  and  in  this  cavity,  which  is  a  sort  of 
diverticulum  of  the  gall-bladder,  the  stones,  bathed  in 
pus,  may  lie.  These  circumstances  may  all  occur  with 
empyema  or  with  acute  cholecystitis,  without  blockage 
of  the  cystic  duct. 

Jaundice  is  more  likely  to  occur  in  the  acutest  forms  of 
empyema  than  in  hydrops  or  in  the  less  acute  forms. 
This  is  due  either  to  an  extension  of  inflammation  along 
the  cystic  duct  to  the  common  duct,  an  acute  cholangitis 
that  is,  or  to  a  peritoneal  inflammation  which,  by  the  de- 
posit of  lymph,  compresses  or  kinks  the  common  duct. 

The  following  series  of  cases  illustrate  the  various  grades 
in  the  intensity  of  an  infection  which  depends  upon  the 
blockage  of  the  cystic  duct  by  a  stone : 

Case  I. — Miss  G.,  aged  fifty-one,  seen  with  Dr.  Johnson, 
of  Bawtry,  July,  1899.  The  history  was  that  forty-eight 
hours  before  I  saw  her  there  was  a  sudden  sharp  attack  of 
abdominal  pain  and  vomiting,  which  was  attributed  to  a 
dietary  indiscretion.  Pain  had  increased,  vomiting  had 
been  serious,  and  at  the  end  of  twenty -four  hours  a  tense, 
rounded  swelling  was  felt  in  the  abdomen. 

On  examining  the  patient  I  found  a  smooth,  hard,  ovoid 
swelling  at  the  ninth  costal  cartilage,  which  was  clearly  a 
distended  gall-bladder.  It  was  tender  on  pressure,  and 
manipulation  caused  a  sense  of  sickness.  I  opened  the 
abdomen,  found  the  gall-bladder  full  of  bile-stained  fluid, 
and  a  stone  impacted  in  the  cystic  duct.  The  stone  was 
worked  back  into  the  gall-bladder  and  removed.  No 
other  stones  were  found.  The  patient  made  a  quick 
recovery  and  has  since  remained  perfectly  well. 

Case  2. — Mrs.  S.,  aged  thirty,  seen  July,  1900,  with 
Dr.  Waugh,  Skipton.  There  was  impaction  of  stone  in 
the  cystic  duct,  followed  by  hydrops  of  the  gall-bladder. 


i6o        Special  Symptoms  in  Gall-stone  Disease 

The  patient  has  suffered  from  pain  in  the  right  hypo- 
chondriac region  for  several  years ;  on  a  few  occasions  has 
been  jaundiced  and  the  motions  have  been  like  "  drab 
paint."  Four  weeks  ago  a  severe  attack  of  pain,  followed 
by  jaundice,  which  lasted  seven  days.  Soon  after  the 
attack  subsided  a  lump  was  felt  beneath  the  ribs  on  the 
right  side;  the  swelling  has  gradually  increased  in  size, 
has  become  exquisitely  tender.  On  several  occasions 
has  had  severe  attacks  of  vomiting. 

The  tumour  was  diagnosed  as  a  distended  gall-bladder. 
On  opening  the  abdomen  a  large,  fully  distended  gall- 
bladder, equal  in  size  to  a  large  lemon,  was  found.  The 
surface  was  injected,  and  there  were  many  adhesions  to 
the  omentum,  stomach,  liver,  and  abdominal  wall.  These 
were  separated  and  the  larger  ones  ligatured.  The  gall- 
bladder was  aspirated,  about  eight  ounces  of  thin  clear 
mucoid  fluid  removed,  and  the  gall-bladder  then  incised. 
A  stone  impacted  in  the  cystic  duct  was  gradually  pushed 
backwards  into  the  gall-bladder  and  removed;  it  was 
almost  as  large  as  a  nutmeg  and  was  solitary.  The  gall- 
bladder was  drained  for  ele^'en  days.  Recovery  was 
uninterrupted. 

Case  3. — Mr.  C.  B.,  aged  thirty-eight.  Sent  by  Dr. 
Booth,  Grimsby.  The  patient's  first  attack  of  gall-stone 
colic  was  five  years  ago;  it  was  followed  by  jaundice, 
which  lasted  only  a  few  days.  Two  years  ago  there  was 
a  similar  attack,  and  since  this  the  patient  has  had  some 
difficulty  and  pain  after  an  ordinary  meal.  Three  weeks 
before  I  saw  him  a  third  attack  of  colic  occurred,  followed 
by  jaundice  lasting  one  week.  During  this  attack  and 
subsequently  he  noticed  that  the  motions  were  pale  and 
the  urine  high  coloured.  A  tumour  formed  beneath  the 
right  rib  margin,  and  assumed  the  size  and  shape  of  a 
cocoanut.  During  the  first  week  it  steadily  increased, 
then  remained  stationary  for  about  a  week,  and  has  since 
very  gradually  diminished. 


Acute  Cholecystitis  i6i 

I  operated  April,  1902,  and  found  the  gall-bladder 
much  enlarged,  and  the  omentum  and  stomach  a  little 
adherent;  on  aspiration  about  seven  ounces  of  thick, 
dirty-looking  bile  were  removed.  A  stone  equal  to  a 
Barcelona  nut  was  found  in  the  cystic  duct  and  six  other 
stones  in  the  gall-bladder.  The  hepatic  and  common 
ducts  were  free.  The  stones  were  removed  and  the  gall- 
bladder drained  for  eight  days.  The  w^ound  then  healed 
and  the  patient  has  since  been  in  excellent  health. 

Case  4. — Mrs.  T.,  aged  forty-one.  Seen  March,  1901, 
with  Dr.  Wiseman,  Leeds.  For  the  last  three  months  has 
suffered  from  pain  and  tenderness  on  the  right  side  of 
the  abdomen.  Sickness  has  been  a  troublesome  symptom, 
and  wasting  a  marked  feature.  The  attacks  of  pain  are 
referred  to  the  right  side  of  the  abdomen  at  about  the  level 
of  the  umbilicus.  Four  days  ago  an  acute  attack  closely 
simulating  intestinal  obstruction  came  on.  There  were 
vomiting,  hiccough,  constipation,  and  marked  prostration. 
A  tumour  was  then  found  on  the  right  side  of  the  abdo- 
men, almost  entirely  below  the  umbilicus  and  vertical  in  its 
longest  diameter.  The  liver  edge  could  be  indistinctly 
felt  just  above  the  swelling.  The  abdomen  was  opened 
and  the  tumour  found  to  be  a  largely  distended  gall- 
bladder containing  pus  and  forty-six  stones.  A  single  stone 
was  tightly  wedged  in  the  cystic  duct.  The  gall-bladder 
was  deeply  congested,  and  a  few  omental  and  colic  adhe- 
sions were  found.  The  stones  were  removed  and  the 
gall-bladder  drained  for  eleven  days.  An  uninterrupted 
recovery  followed. 

(b)  Acute  Cholecystitis. — This  in  its  various  forms  is 
the  most  common  variety  of  inflammation  caused  by 
gall-stones.  Indeed,  many  of  the  symptoms  in  the 
slighter  attacks  of  gall-stone  disease  are  due  to  a  mild 
cholecystitis.     AVhen    the    gall-stone    becomes    blocked 


1 62        Special  Symptoms  in  Gall-stone  Disease 

in  the  entrance  of  the  cystic  duct,  an  infection  speedily 
follows,  effusion  takes  place  into  the  gall-bladder,  and 
inflammation  of  its  walls  speedily  follows.  Acute  chole- 
cystitis is  therefore  the  precursor  both  of  hydrops  and 
of  empyema  of  the  gall-bladder.  The  inflammation 
may  also  start  at  the  fundus  of  the  gall-bladder  or  in- 
deed at  any  part  of  the  walls.  The  swelling  rapidly 
spreads  over  the  whole  mucosa,  and  when  it  reaches 
the  orifice  of  the  cystic  duct,  the  swelling  of  the  mucosa 
effectually  blocks  the  passage  down  the  duct.  In  acute 
cholecystitis  the  occlusion  of  the  cystic  duct  may  be 
primary,  causing  the  cholecystitis,  or  secondary,  result- 
ing from  the  cholecystitis.  The  block  may  be  due  to 
impacted  stone,  to  swelling  of  the  mucosa,  to  kink  of 
the  cystic  duct,  or  to  swelling  of  the  gland  which  is 
normally  present  at  the  first  bend  of  the  duct. 

The  symptoms  of  an  acute  cholecystitis  are  identical 
with  those  caused  in  the  early  stage  of  a  "regular"  chole- 
lithiasis, save  for  the  fact  that  the  gall-bladder  is  always 
enlarged,  is  palpable,  and  is  tender  on  pressure.  Jaun- 
dice is  never  present  unless  the  inflammation  extends 
down  to  the  cystic  duct  and  affects  the  mucosa  of  the 
common  duct.  Such  an  extension  is  extremely  rare. 
The  enlarged  gall-bladder  is  sometimes  the  seat  of  acute 
pain,  which  may  radiate  into  the  chest,  back,  or  abdo- 
men. The  side  is  stiff'  and  sore  for  several  days.  The 
varieties  of  acute  inflammation  described  are  catarrhal, 
suppurative,  and  gangrenous.  The  catarrhal  form,  and 
indeed  the  other  forms,  may  arise  in  the  absence  of 
gall-stones,  but  in  the  great  majority  of  instances  it 
is  the  damage  done  by  a  calculus  that  opens  the  path 
of  infection. 


Acute  Cholecystitis  163 

In  acute  cholecystitis  the  symptoms  are  not  seldom 
those  of  an  acute  appendicitis;  the  signs  also  are  sim- 
ilar, though  in  the  one  the  upper  part,  and  in  the 
other  the  lower  part,  of  the  abdomen  on  the  right  side 
is  affected.  Pain  is  the  first  symptom;  it  is  sudden  in 
onset  and  increases  rapidly;  it  is  both  paroxysmal 
and  continuous.  It  is  felt  chiefly  over  the  liver,  es- 
pecially along  the  liver  border,  but  it  may  radiate 
widely  in  several  directions  and  may  even  mimic  the 
pain  of  appendicitis  or  of  subacute  perforation  of  the 
stomach  or  duodenum.  It  is  not  long  before  other 
symptoms  of  infection  occur,  nausea  and  perhaps  vom- 
iting, prostration,  collapse,  marked  rigidity,  and  tender- 
ness in  the  gall-bladder  area.  If  there  is  a  peritoneal 
infection  of  wide  extent,  the  symptoms  are  more  severe 
than  those  depicted.  In  some  instances,  indeed,  they 
may  so  closely  resemble  those  of  an  acute  intestinal 
obstruction  as  to  lead  to  an  operation  for  that  condi- 
tion; and  it  is  only  during  the  manipulations  that  it 
is  recognised  that  the  gall-bladder  is  the  cause  of  the 
symptoms.  The  temperature  is  generally  raised  to  100° 
or  even  higher;  the  pulse  too  is  rapid  and  weak.  In 
this,  as  in  all  other  abdominal  conditions,  the  pulse  is 
the  safe  guide,  and  is  more  to  be  depended  on  than 
the  temperature. 

The  organism  found  is  generally  the  bacillus  coli, 
but  in  the  suppurative  forms  the  streptococcus  pyogenes 
aureus  and  albus  or  staphylococci  may  be  present. 
The  bacillus  of  Eberth  and  the  pneumococcus  are  also 
found. 

So  long  as  the  inflammation  is  limited  to  the  mucosa 


164        Special  Symptoms  in  Gall-stone  Disease 

it  does  not  give  rise  to  acute  symptoms,  nor  does  it 
endanger  the  life  of  the  patient.  Such  a  condition  of 
infection,  however,  is  produced  that  subsequent  troubles 
from  redisturbance  of  the  stones  or  a  fresh  accession 
of  inflammation  will  almost  without  exception  be 
found  to  follow;  that  is  to  say,  that  gall-stones  which 
have  once  caused  cholecystitis  will  rarely,  if  ever, 
become  quiescent. 

In  many  cases  the  inflammation,  even  when  apparently 
slight  in  character,  as  estimated  by  the  clinical  disturb- 
ance, has  been  of  sufficient  severity  to  penetrate  to  the 
serous  coat.  A  pericholecystitis  is  caused,  a  local  peri- 
tonitis involving  the  serous  coat  of  the  gall-bladder  and 
the  immediately  adjacent  structures.  The  formation 
of  a  plastic  lymph,  which  in  recent  cases  can  be  peeled 
off  in  thin  layers,  is  the  result,  and  this  at  the  last  leads 
to  the  firm  adhesions  which  may  be  so  troublesome  a 
feature  in  any  operative  procedure.  Adhesions  so 
formed  may  in  certain  infrequent  cases  persist  long 
after  the  stone  or  stones  which  have  caused  them  have 
passed,  and  they  may  cause  symptoms  which  are  not 
to  be  distinguished  from  those  due  to  the  imtation 
of  gall-stones. 

When  the  acute  inflammation  has  subsided,  a  thicken- 
ing of  the  gall-bladder  is  left.  There  is  never  a  resti- 
tution to  the  normal;  a  chronic  cholecystitis  remains. 
When  a  fresh  infection  occurs,  the  chronic  cholecystitis 
becomes  acute,  and  this  again  subsides.  There  is  an 
alternation  then  between  acute  and  chronic  cholecystitis 
to  the  serious  and  increasing  impairment  of  the  gall- 
bladder. 


Acute  Cholecystitis  165 

When  the  inflammation  spreads  to  the  serous  coat, 
a  local  peritonitis,  easily  recognisable  on  clinical  ex- 
amination, speedily  develops.  The  condition  then  is 
only  a  degree  less  acute  than  that  present  in  acute 
phlegmonous  cholecystitis,  to  be  presently  described. 
The  signs  and  the  symptoms  are  those  of  an  acute  local- 
ised peritoneal  infection.  As  a  rule,  the  rigidity,  ten- 
derness, and  pain  are  limited  to  an  area  immediately 
below  the  free  edge  of  the  liver.  The  condition  is  one 
which  demands  early  surgical  treatment.  Korte  has 
related  17  cases  of  acute  cholecystitis  upon  which  he 
operated.  Stones  were  present  in  16  cases,  absent  in  i, 
but  in  this  a  stone  had  probably  been  present  a  little 
earlier.  Of  these  cases  there  were  7  in  which  the  stones 
had  been  absolutely  latent,  there  were  5  in  which  symp- 
toms were  present  but  had  led  to  an  erroneous  diag- 
nosis of  stomach  or  kidney  disease;  in  the  remaining  4 
gall-stones  had  been  diagnosed.  In  6  cases  cholecys- 
totomy  and  drainage,  in  5  cholecystectomy  and  tampon- 
age,  in  6  cholecystectomy  and  drainage  of  the  common 
duct  were  practised. 

There  is,  however,  a  much  more  serious  form  of  in- 
flammation of  the  gall-bladder  than  these — phlegmonous 
cholecystitis.  This  disease  was  first  described  by  Cour- 
voisier  in  his  memorable  paper  in  1890.  He  collected 
7  cases,  and  described  them  as  "acute  progressive  empy- 
ema of  the  gall-bladder. ' '  The  following  cases  which  were 
under  my  care  illustrate  the  gravity  of  the  condition : 

Case  I. — Phlegmonous  Cholecystitis:  Sloughing  and 
Perforation  of  Gall-bladder.— M.  A.,  aged  forty-six;  male. 


1 66        Special  Symptoms  in  Gall-stone  Disease 

Patient  seen  with  Dr.  Erskine  Stuart,  Batley.  Had 
been  perfectly  well  up  to  December  31,  1900.  On  that 
day  he  had  a  sharp  attack  of  pain  in  the  right  hypo- 
chondriac region  about  an  hour  after  his  evening  meal. 
He  felt  sick  and  cold,  vomited  several  times,  and  could 
only  obtain  ease  by  doubling  himself  over  the  back  of 
a  chair.  He  was  given  a  large  dose  of  opium  and  put 
to  bed.  The  next  day  he  was  slightly  jaundiced;  the 
day  following  more  so,  and  the  jaundice  has  persisted. 
Pain  in  the  right  hypochondrium  has  been  constant — 
relief  had  only  been  obtained  by  opium  administra- 
tions. 

On  examination,  January  11, -1901,  the  patient  was 
found  moderately  jaundiced  and  looking  ill.  The  abdo- 
men was  full  and  prominent;  the  whole  right  hypo- 
chondriac region  was  hard,  strongly  resisting,  tender  on 
pressure.  The  muscular  protection  was  so  effective  that 
no  deep  examination  was  possible.  A  diagnosis  of 
cholangitis  and  cholecystitis,  depending  possibly  upon 
calculus,  was  made.  The  rigidity  and  tenderness  were 
supposed  to  be  due  to  a  localised  peritonitis,  possibly 
dependent  upon  distension  of  the  gall-bladder  as  a  result 
of  obstruction  of  the  cystic  duct. 

The  abdomen  was  opened  on  January  12th  by  an 
incision  through  the  right  rectus  muscle.  On  opening 
the  peritoneum  bile-stained  liquid  with  flocculent  masses 
of  lymph  flowed  from  the  wound.  At  the  least  three 
pints  of  fluid  were  removed.  A  collection  was  found 
between  the  liver  and  the  diaphragm,  the  fluid  there 
being  thick  and  semi-purulent.  An  examination  of  the 
gall-bladder  disclosed  the  cause  of  the  condition.  The 
gall-bladder  was  thickly  coated  with  lymph,  was  deep- 
purple  in  colour,  and  shewed  a  sloughing  opening  on 
its  surface  from  which  bile-tinged  fluid  was  oozing.  The 
opening  was  about  one  and  one-fourth  inches  in  diameter ; 
its  edges  were  ragged  and  a  little  thickened.     In   the 


Acute  Cholecystitis  167 

gall-bladder  seven  stones  were  found;  an  eighth,  the 
largest,  was  discovered  later  in  the  upper  part  of  the 
renal  pouch,  partly  buried  in  lymph.  The  cavity  was 
cleaned  up  as  well  as  possible,  the  gall-bladder  opening 
trimmed,  and  a  drainage-tube  secured  in  it;  the  sub- 
phrenic abscess  was  separately  drained,  and  a  tube  was 
also  passed  in  through  a  stab  wound  in  the  loin. 

The  patient,  whose  condition  was  bad  before  the  opera- 
tion, died,  gradually  declining  in  forty-eight  hours. 

Case  2. — Gangrene  and  Perforation  of  the  Gall-bladder. — 
W.  D.,  male,  aged  fifty-tw^o.  Admitted  Sept.  9,  1902, 
with  the  following  history : 

The  patient  has  suffered  from  indigestion,  biliousness, 
and  discomfort  after  food  for  twenty-five  years,  when 
he  had  typhoid  fever;  the  vomiting,  first  observed  five 
years  later,  was  at  first  infrequent  and  copious.  Eight 
years  ago  his  condition  became  worse.  He  had  constant 
severe  pain  after  food,  frequent  vomiting,  often  twice 
daily,  and  lost  over  a  stone  in  weight  in  about  three 
months.  He  improved  a  little  during  the  following  year 
but  has  since  steadily  lost  health  and  strength.  Six 
months  ago  was  seen  by  an  eminent  physician  who 
diagnosed  "cancer  of  the  stomach."  His  loss  of  flesh 
has  latterly  been  extreme,  he  is  now  very  sallow,  wasted, 
and  feeble.  The  stomach  reaches  midwa}^  between  um- 
bilicus and  pubes,  can  be  seen  contracting  on  distension. 
Free  HCl  present  in  small  quantity.  At  the  operation, 
the  condition  found  was  a  dilated  and  somewhat  hyper- 
trophied  stomach.  A  large  thick  mass  in  the  duodenum, 
involving  the  pancreas,  was  found,  and  was  thought  to 
be  malignant.  The  stomach  was  much  dilated  and  its 
coats  were  thickened.  Posterior  gastro-enterostomy  was 
performed  and  all  went  well  for  twenty-eight  days.     At 


1 68        Special  Symptoms  In  Gall-stone  Disease 

the  end  of  that  time  the  patient  became  suddenly  very 
ill.  Collapse  and  the  vomiting  of  bile  were  the  chief 
features  and  jaundice  quickly  followed.  The  abdomen 
was  distended  and  exquisitely  tender  over  the  hepatic 
area.  The  abdomen  was  re-opened  and  a  gangrenous 
and  perforated  gall-bladder  was  found.  Bile  was  seen 
escaping  from  the  openings  in  the  gall-bladder.  The 
gall-bladder  and  the  peritoneum  were  drained,  but  the 
patient  died  in  a  few  hours.  It  was  found  that  the 
malignant  growth  had  involved  the  pancreas  along  its 
upper  and  right  margin,  and  the  hepatic  artery  was 
imbedded  in  the  growth. 


This  case  is  instructive  as  only  three  small  gall-stones 
were  found  either  in  the  gall-bladder  or  the  ducts,  and 
the  patency  of  the  ducts  during  life  was  shewn  by  the 
vomiting  of  bile.  The  interference  with  the  blood  sup- 
ply was  undoubtedly  the  cause  of  the  gangrene. 

The  condition  is  clearly  analogous  to  the  acute  phleg- 
monous appendicitis  which  is  occasionally  seen ;  both  are 
conditions  in  which  the  bacterial  virulence  is  so  exces- 
sive that  a  complete  destruction  of  the  appendix  or 
gall-bladder  is  accomplished  before  the  peritoneum 
has  had  the  time  to  protect  itself  by  the  out-pouring 
of  serum  or  lymph. 

The  symptoms  of  phlegmonous  cholecystitis  are  of 
the  gravest  type.  There  is  a  sudden  onset  of  very  acute 
pain  in  the  right  hypochondrium.  This  may  be  so  pro- 
found as  to  cause  collapse,  faintness,  and  great  prostra- 
tion. The  pain  comes  generally  on  without  obvious  cause, 
but  in  not  a  few  instances  it  has  been  attributed  to  the 
taking  of  an   unduly   heavy   meal.     The   constitutional 


Pressure  Effects  of  Stone  in  Cystic  Ducts      169 

disturbance  is  alarming.  The  pulse  is  rapid,  feeble, 
almost  running;  the  hands  and,  indeed,  the  body  sur- 
faces generally  are  cold,  clammy,  covered  with  sweat; 
there  is  sometimes  a  rigor,  but  always  an  elevation 
of  temperature  during  the  first  few  hours.  The  local 
signs  are  seen  early,  and  are  those  of  a  peritonitis, 
limited  at  first  to  the  gall-bladder  region,  but  later  be- 
coming generalised. 

(c  and  d)  Sclerosis  and  calcification  of  the  gall-bladder 
occur  at  a  late  stage  of  the  disease  and  are  the  results 
of  a  dense  inflammatory  deposit  in  the  walls  of  the 
viscus.  The  symptoms  are  those  of  chronic  cholecystitis, 
and  have  already  been  detailed. 


PRESSURE  EFFECTS  OF  STONE  IN  THE  CYSTIC  DUCTS. 

In  addition  to  all  these  conditions  a  stone  impacted 
in  the  c\^stic  duct  may,  by  its  pressure  upon  the  common 
duct,  portal  vein,  or  duodenum,  give  rise  to  symptoms 
which  tempt  the  surgeon  to  an  erroneous  diagnosis.  The 
pressure  upon  the  common  duct  causes  cholangitis,  and 
the  symptoms  of  a  stone  in  the  duct  are  portrayed. 
Pressure  upon  the  portal  vein  causes  thrombosis  and 
ascites.  If  both  the  common  duct  and  the  portal  vein 
are  compressed,  there  will  be  jaundice  and  ascites,  and 
a  diagnosis  of  malignant  disease  will  be  suggested. 
Pressure  upon  the  duodenum,  as  in  two  cases  recorded 
by  Mikulicz,  has  caused  the  symptoms  of  gastric  dila- 
tation. 

The  following  illustrative  examples  may  be  quoted. 
In    a    discussion    before    the    Chicago    Surgical    Society 


I  70        Special  Symptoms  in  Gall-stone  Disease 

(Annals  of  Surgery,  vol.  35,  p.  666)  Dr.  McArthur  gave 
the  following  account  of  a  case : 


Last  July  he  had  occasion  to  make,  as  a  last  resort, 
an  operation  upon  a  patient  in  the  practice  of  Dr.  Favill, 
who  had  been  seen  by  von  Jaksch  in  Prague,  and  who 
had  sent  him  immediately  home  to  undoubtedly  die, 
as  he  said,  from-  malignant  disease  of  the  liver,  with 
no  thought  of  operation.  When  the  patient  reached 
Chicago,  he  was  seen  by  Dr.  Fenger,  the  diagnosis  of 
malignant  disease  of  the  liver  confirmed,  and  "hands 
off"  the  verdict.  This  man  was  in  that  terrible  condi- 
tion which  obtains  after  six  months'  persistent  jaundice, 
and,  in  addition  to  an  enlarged  and  hardened  liver, 
he  had  extreme  ascites.  On  reviewing  the  history  with 
Dr.  Billings  and  Dr.  Favill,  he  suggested  that,  as  a 
dernier  ressort,  at  least  an  exploratory  laparotomy  be 
made;  if  a  stone  be  found,  to  give  the  patient  relief; 
and  if  it  were  possible,  to  make  a  cholecystenterostomy 
to  do  that,  and  relieve  the  jaundice.  In  the  face  of 
fatal  issue,  w^hich  the  patient  was  told  might  easily  and 
quickly  ensue  because  of  the  dangers  of  haemorrhage 
and  of  his  great  emaciation,  patient  requested  an  opera- 
tion. A  quick  exploration  of  the  gall-bladder  was  made. 
The  gall-bladder  w^as  found  packed  with  stones,  with  one 
large,  barrel-shaped  stone  plugging  the  cystic  duct.  The 
patient  died  on  the  third  day  after  the  operation. 
Nothing  was  seen  of  malignant  character  at  time  of 
operation  except  nodule  on  liver  edge.  A  partial  post- 
mortem examination  revealed  on  the  margin  of  the  liver, 
at  a  point  close  to  the  gall-bladder,  a  small  hazelnut- 
sized  tumour,  which  was  removed  for  examination,  and 
was  pronounced  an  adenoma;  but  no  malignant  disease 
of  the  liver,  the  duodenum,  the  stomach,  or  pancreas  was 
seen. 


I 


Pressure  Effects  of  Stone  In  Cystic  Ducts      171 

A  similar  case  to  this  was  under  the  care  of  Dr.  Moore 
of  Minneapohs.  Jaundice  and  ascites  were  present;  a 
stone  was  found  impacted  in  the  cystic  duct,  compress- 
ing the  common  duct  and  the  portal  vein.  It  was  re- 
moved and  the  patient  recovered. 

For  the  notes  of  the  following  case  I  am  indebted 
to  Dr.  Barrs  (the  patient  was  under  the  care  of  Mr. 
Littlewood,  and  subsequently  of  Dr.  Barrs  in  the  Leeds 
Infirmary) : 

Female,  aged  fifty-nine.  November  18,  1903.  Patient 
was  well  up  to  six  years  ago,  when  present  illness  began ; 
always  temperate,  no  venereal  disease,  has  had  14  children ; 
well-built,  fairly  stout  woman.  Illness  began  quite  sud- 
denly with  violent  "tearing  "  pain  in  upper  part  of  right 
side  of  "body."  She  was  doubled  up,  vomited  and 
sweated  profusely.  The  attack  lasted  about  twelve 
hours,  and  she  was  yellow  for  three  weeks  after.  Her 
motions  were  white  and  her  urine  dark,  and  she  was  in 
bed  one  week  and  attended  by  a  doctor.  Except  for 
slight  pain  in  her  right  side,  she  got  quite  well. 

Two  years  ago  she  had  a  severe  attack  of  pain  and  again 
one  year  ago,  but  was  not  jaundiced  so  far  as  she  knows. 

In  September,  1903,  she  says  she  first  noticed  "  her  body 
was  swollen"  and  that  she  was  becoming  "yellow  in  the 
eyes  "  ;  then  she  noticed  that  her  urine  was  dark  coloured 
(just  as  it  had  been  in  her  severe  jaundice  attack  six 
years  before)  and  "smelled  badly";  she  became  consti- 
pated and  her  stools  were  white.  She  went  to  a  doctor  to 
have  her  urine  examined  and  was  given  pills  which  re- 
lieved her  constipation.  About  the  middle  of  September 
she  felt  cold  and  chilly  and  went  to  bed,  and  for  two  or 
three  weeks  vomited  most  of  her  food.  Her  appetite  was 
bad  and  she  was  very  thirsty ;  the  distension  of  the  "  body  " 


1/2        Special  Symptoms  in  Gall-stone  Disease 

increased  and  the  legs  swelled  a  little.  On  October  20th, 
the  doctor  drew  off  from  the  peritoneal  cavity  1 1  pints 
of  dark  fluid.  She  rapidly  filled  again  and  was  admitted 
to  Leeds  General  Infirmary  on  October  23d. 

On  examination,  marked  jaundice;  stools  not  clay-col- 
oured; urine,  sp.  gr.  1012,  bile  present,  no  albumin,  no 
sugar,  much  ascites  with  usual  signs,  but  the  liver  is  pal- 
pable through  it.  Liver  reaches  one  to  two  inches  below 
costal  margin,  edge  sharp,  regular,  not  tender,  moves  freely 
on  respiration,  absolute  dulness  reaches  sixth  rib  in  mid- 
axillary  line.  Below  margin  of  liver,  opposite  tenth  right 
costal  cartilage,  the  hand  "dips"  through  fluid  on  to  a 
mobile,  rounded  lump,  probably  gall-bladder. 

Her  general  condition  was  fair ;  no  distended  ^'eins  were 
seen ;  all  other  organs  are  normal. 

November  i6th:  Abdomen  tapped  and  9I  pints  of  dark, 
bilious,  transparent  fluid  withdrawn. 

November  17th:  Not  quite  so  well,  feels  weaker,  fluid 
accumulating  somewhat  rapidly.  Five  p.  m.,  much  worse, 
pain  in  abdomen,  more  fluid  in  peritoneal  cavity,  pulse  still 
good.  Hot  fomentations  applied  tightly  to  abdomen, 
and  calcium  chloride,  gr.  xx,  given  two  hourly,  because 
haematemesis  feared ;  some  vomiting,  some  dyspnoea. 

Ten  p.  M.,  still  sinking  rapidly,  fluid  now  fllls  peritoneal 
cavity,  pulse  good,  anxious  expression,  probably  bleeding 
into  peritoneal  cavity. 

November  i8th:  4.15  a.m.,  death. 

P.  M.  November  i8th:  Body  jaundiced,  abdomen  dis- 
tended with  fluid,  peritoneal  cavity  full  of  bloody  fluid 
and  blood  clots  amounting  to  6  pints ;  no  place  could  be 
found  except  the  recent  wound  through  which  tapping 
had  been  done  from  which  the  hsematemesis  had  come,  al- 
though the  whole  peritoneal  surface  looked  very  vascular. 
A  clot  was  adherent  to  puncture  wound  on  peritoneum. 
Liver  generally  enlarged,  bile-stained  surface  finely  gran- 
ular, substance  distinctly  tough  (early  cirrhosis?).      Gall- 


Pressure  Effects  of  Stone  in  Cystic  Ducts      173 

bladder  sausage-shaped,  4^  inches  long,  2  inches  broad, 
containing  multitude  of  minute  stones  in  clear  mucus. 
Hepatic  ducts  markedly  dilated.  Half  stone  about  size 
of  a  medium-sized  Barcelona  nut.  Common  bile-duct  is 
dilated,  contained  a  few  minute  stones  and  bile-stained 
mucus.  The  stone  in  the  cystic  duct  pressed  against  the 
common  duct,  almost  occluding  it,  the  duct  being  dilated 
above  and  natural  below  the  point  of  pressure.  The  stone 
in  the  cystic  duct  also  exerted  pressure  upon  the  portal 

Hepatic  ducts. 

Cystic  duct. 

Line  of  pressure 


Portal  vein. 

Common  bile-duct. 
Hepatic  artery. 


Fig.  42. — Drawing  made  by  Mr.  L.  R.  Braithwaite,  who  performed  the 
postinortem  examination. 


vein,  there  being  slight  peritonitic  adhesions  between 
them  at  this  point,  although  the  portal  vein  was  readily 
patent  to  a  probe  passed  from  below.  A  probe  passed 
easily  from  junction  of  cystic  with  common  bile-duct  along 
into  the  duodenum. 

Pancreas. — Markedly  large.  Substance  unusually  hard 
and  gritty.  Head  very  hard  and  large.  Substance  on 
section  appears  normal. 

Microscopical  Examination  (Dr.  Forsyth) :  "  Pancreas 
shows  an  early  stage  of  chronic  pancreatitis." 


I  74        Special  Symptoms  in  Gall-stone  Disease 

Courvoisier  records  four  cases  in  which  the  portal  vein 
contained  a  gall-stone  which  had  ulcerated  into  it  from 
the  gall-bladder  or  ducts.    . 


(C)  STONES  IN  THE  HEPATIC  DUCT. 

Stones  in  the  hepatic  duct  are  less  commonly  seen  than 
stones  in  any  other  part  of  the  bile  passages.  As  a  rule, 
when  there  are  stones  in  the  hepatic  duct  there  are  others 
in  the  common  duct  or  in  the  gall-bladder.  This,  how- 
ever, is  not  universally  the  case. 

In  59  cases  collected  by  Courvoisier,  in  56  stones  were 
present  in  other  parts  of  the  bile  passages.  In  51,  in 
which  distinct  mention  is  madeof  the  condition  of  the  com- 
mon duct,  there  were  stones  therein  in  45.  Small  stones 
composed  of  bilirubin  calcium  are  not  infrequently  found 
in  the  hepatic  duct  when  this  is  explored  after  the  re- 
moval of  a  stone  from  the  common  duct.  Such  small 
calculi  are  black  or  dark  brown  in  colour  and  are  readily 
compressed  to  a  fine  powder  by  the  pressure  of  the 
fingers. 

Michaux  (Bull.  Soc.  Chir..  1894)  comments  upon  the 
extreme  infrequency  of  stone  in  the  hepatic  duct.  In 
a  search  through  the  Bull,  de  la  Soc.  de  Chir.  since  its 
foundation,  in  1826,  only  eight  cases  of  stone  in  this  duct 
were  found  recorded.  In  almost  all  the  cases  a  large  calcu- 
lus was  also  found  in  the  common  duct.  Michaux  ex- 
pressed the  opinion  that  hepatic  stone  was  always  secon- 
dary to  stone  in  other  parts  of  the  biliary  passages. 

Stones  may  be  formed,  though  this  is  probably  very 
rare,  in  the  hepatic  duct,  and  there  remain  stationary, 


Stones  in  the  Hepatic   Duct  175 

gradually  enlarging  by  added  deposits  from  the  bile  stream, 
or  they  may,  and  in  the  very  great  maJQrity  of  cases  they 
doubtless  do,  pass  down  from  the  gall-bladder  along  the 
cystic  duct  and  turn  upwards  into  the  wider  hepatic  duct, 
whether  the  common  duct  be  blocked  or  free.  A  single 
stone  may  be  found ;  more  commonly  there  are  many. 
When  solitary,  the  stone  is  generally  of  the  size  of  a 
nutmeg,  or  even  larger. 

The  symptoms  due  to  a  stone  or  stones  in  the  hepatic 
duct  are  not  separable  from  those  due  to  blocking  of  the 
common  duct. 

The  following  is  the  record  of  a  case  which  was  under 
my  care: 

Case  8. — Mrs.  T.  B.,  aged  39.  Seen  with  Dr.  Sproulle, 
Mirfield.  Three  years  ago  she  had  an  attack  of  epigastric 
pain  and  vomiting,  followed  by  slight  jaundice — a  typical 
attack  of  biliary  colic.  Since  then  she  has  had  nine  simi- 
lar but  progressively  more  severe  attacks.^  Nine  weeks 
ago  an  extremely  severe  attack.  Pain  has  continued  all 
the  time,  and  jaundice,  though  varying  slightly,  has  al- 
ways been  pronounced.  The  motions  during  this  period 
have  been  light  coloured,  the  urine  thick  and  scanty. 
Pain  is  constant,  but  at  times  an  acute  paroxysm  occurs. 
Has  lost  flesh  rapidly  during  the  last  two  months,  and  has 
been  eating  little,  owing  to  pain  and  heaviness  after  even 
light  diet,  and  vomiting. 

Operation,  December  7,  1900. — Eighty-seven  gall-stones 
\yere  removed,  mostly  from  the  hepatic  and  common  ducts. 
A  few  lay  in  the  gall-bladder,  but  both  hepatic  ducts  and 
the  whole  length  of  the  common  duct  were  filled  with 
tightly  packed  stones.  These  were  removed  through  an 
incision  in  the  common  duct,  which  was  afterwards  sewn 
up.     A  stone  was  found  tightly  impacted  in  the  ampulla 


176        Special  Symptoms  in  Gall-stone  Disease 

of  Vater,  and  the  duodenum  had  to  be  opened  in  order  to 
remove  it. 

The  patient  had  severe  haematemesis  after  the  operation 
and  died  on  the  third  day. 

Stones  in  the  hepatic  duct  are  liable  to  be  overlooked. 
I  have  on  several  occasions  found  well-formed  stones 
unexpectedly  in  the  hepatic  duct,  or  in  one  of  the  branches, 
when  engaged  in  removing  stones  from  the  common  duct. 
In  all,  the  stones  were  easily  milked  downwards  and  re- 
moved through  the  common  duct  incision.  In  some  cases, 
however,  the  separate  opening  and  draining  of  the  hepatic 
may  be  needed. 

When  infective  or  suppurative  cholangitis  occurs, 
the  outlook  is  desperate  indeed.  Xaunyn  relates  a  case 
from  the  practice  of  Kussmaul  in  which,  after  cholelithiasis 
of  many  years'  duration  and  three  weeks  of  fever  with 
jaundice  and  rigors,  the  patient  succumbed  to  marasmus. 
At  the  autopsy  the  hepatic  duct  was  blocked  by  a  concre- 
tion. Its  branches  and  the  intra-hepatic  ducts  were  blocked 
throughout.  The\'  formed  a  system  of  mutually  commu- 
nicating sinuous  cavities,  varying  from  the  size  of  a  millet 
seed  to  that  of  a  cherry  stone.  Within  the  liver,  near  its 
hilus,  these  cavities  were  so  abundant  that  the  liver  "  resem- 
bled a  bath  sponge  with  larger  and  smaller  perforations." 
These  cavities  were  filled  with  bile-stained  pus,  and  their 
walls  consisted  of  a  distinct  membrane  with  a  ragged 
surface ;  the  liver  tissue  was  dry  and  jaundiced. 

When  suppuration  behind  a  stone  in  the  hepatic  duct 
has  extended  into  the  liver,  the  condition  described  by 
Leonard  Rogers  (Brit.  Med.  Journ.,  vol.  2,  1903,  p.  706) 
as  "biliary  abscess"  results.     There  is  a  universal  suppu- 


Fig.  43. — Dilated  hepatic  duct;  ascending  suppurative  hepatitis. 
The  gall-bladder  is  greatly  contracted,  and  its  cystic  duct  leads  into 
a  cavity  two  inches  across,  produced  by  the  dilatation  of  the  hepatic 
duct,  which  contained  bile  and  pus,  with  many  small  black  calculi. 
The  common  bile-duct,  also  communicating  with  this  cavity,  is  some- 
what dilated  and  contains  a  gall-stone  the  size  of  a  cherry,  impacted 
half  an  inch  from  the  papilla.  Scattered  through  the  liver  and  be- 
neath the  capsule  are  many  small  ragged  abscess-cavities.  From  a 
woman,  aged  thirty,  admitted  for  jaundice  of  fourteen  days'  duration. 
Five  months  previously,  after  a  severe  attack  of  enteric  fever,  a 
swelling  was  noticed  in  the  region  of  the  gall-bladder,  but  this  gradu- 
ally disappeared.  On  admission  the  liver  was  uniformly  enlarged; 
pyrexia  was  present;  she  also  suffered  from  rigors.  After  death,  a 
fortnight  later,  the  liver  was  found  to  weigh  no  ounces,  and  the 
peritoneal  cavity  contained  much  bile-stained,  purulent  lymph  (Guy's 
Hospital  Museum,  No.  141 8). 


177 


178        Special  Symptoms  in  Gall-stone  Disease 

rative  cholangitis,  the  ducts  within  the  liver  being  greatly 
dilated  and  filled  with  pus.  There  may  be  nothing  which, 
even  on  the  closest  scrutiny,  suggests  a  diagnosis  of  gall- 
stone trouble ;  there  may  never  have  been  pain,  vomiting, 
coHc,  or  jaundice.  In  other  cases,  however,  a  history 
suggesting  the  impaction  of  a  stone  in  the  common  duct 
will  have  been  obtained.  Leonard  Rogers  attaches  great 
significance  to  a  group  of  symptoms  which  was  present 
in  more  than  half  the  cases  collected  by  him. 

"  It  consists  of  a  complete  obstructive  jaundice,  which 
is  always  present  in  the  earlier  stages  of  the  disease, 
followed  by  the  reappearance  of  bile  in  the  stools  in 
often  small  quantities  and  a  decrease  in  the  jaundice, 
accompanied  by  an  aggravation  of  the  general  symptoms 
with  rigors  and  hectic  condition,  instead  of  the  ameliora- 
tion naturally  expected  to  ensue  on  the  partial  removal  of 
the  complete  obstruction  of  the  bile-ducts.  This  improve- 
ment in  the  jaundice  and  reappearance  of  bile  in  the  intes- 
tine, together  with  increasingly  severe  general  symptoms, 
is  due  to  softening  and  distension  of  the  wall  of  the  ducts 
by  suppuration  occurring  within  them  above  the  obstruc- 
tion leading  to  loosening  of  the  impacted  stone,  which, 
in  turn,  allows  of  the  escape  of  a  little  of  the  bile  and  pus 
into  the  bowel  past  the  stone." 

He  records  the  following  case : 

The  patient  w^as  in  the  Forest  Department  (Calcutta) , 
and  he  came  in  on  April  6,  1902,  for  the  treatment  of 
enlarged  liver  and  a  history  of  occasional  attacks  of  ague 
and  repeated  attacks  of  jaundice,  preceded  by  severe  pain, 
the  last  of  which  occurred  three  weeks  before  admission. 
The  liver  dulness  extended  from  the  fifth  rib  to  six  inches 


Stones  in  the   Hepatic   Duct  179 

below  the  costal  margin.  Spleen  not  enlarged;  heart 
and  lungs  normal ;  pulse  48;  slight  jaundice;  temperature 
normal.  From  April  13th  to  17th  he  suffered  from  inter- 
mittent fever  and  was  treated  with  quinine.  On  the  2  2d 
he  had  a  rigor,  the  temperature  rising  to  104°,  falling  to 
101°  the  next  morning,  when  I  examined  the  blood  at  the 
request  of  the  physician  under  whom  the  patient  was  at 
that  time,  as  liver  abscess  was  suspected.  I  found  no 
leucocytosis,  but,  on  the  contrary,  they  were  below  the 
normal,  with  a  large  proportion  of  large  mononuclears,  and 
further  search  revealed  malignant  tertian  parasites,  and 
quinine  treatment  was  resumed;  and  with  the  exception 
of  a  slight  rise  on  the  27  th  and  ague  on  May  4th  and  7  th 
no  more  fever  occurred;  the  jaundice  improved  and  he 
left  the  hospital  on  May  i8th,  the  case  at  this  period 
having  been  one  of  biliary  colic,  accompanied  by  malarial 
fever. 

On  December  18,  1902,  he  returned  to  the  hospital  and 
came  under  my  care.  Ill  since  7th  in  bed.  Has  passed 
several  gall-stones  since  the  15th,  which  he  brought  with 
him,  the  largest  being  about  |  inch  in  diameter.  The  liver 
dulness  extended  from  the  fourth  space  to  three  inches, 
and  much  pain  of  a  colicky  nature,  requiring  morphine. 
Temperature  from  100°  to  102°,  with  profuse  perspiration. 
The  fever  continued,  and  on  December  2 2d  he  coughed 
up  a  quantity  of  viscid,  frothy  mucus.  Temperature  of  a 
hectic  type,  continued  rising  to  103°  and  104°  in  the  even- 
ing. The  vocal  fremitus  was  slightly  diminished,  but 
there  was  only  partial  loss  of  resonance  at  the  right  base. 
I  diagnosed  suppuration  in  the  bile-ducts  in  the  liver, 
and  advised  operation  for  the  purpose  of  draining  the 
ducts  and  removing  any  gall-stones.  After  a  consultation 
this  was  agreed  to.  On  the  morning  of  the  2  5th  he  coughed 
up  a  small  quantity  of  pus,  but  in  view  of  the  case  men- 
tioned above,  in  which  a  fatal  termination  ensued  in  an 
abscess  of  this  kind,  in  spite  of  the  opening  through  the 


i8o        Special  Symptoms  in  Gall-stone  Disease 

lung,  and  having  certain  knowledge  of  gall-stones  having 
been  passed,  it  was  decided  to  proceed  with  the  operation 
as  previously  arranged,  Captain  H.  Alackin,  I.  M.  S., 
kindly  helping  me. 

Operation. — An  incision  was  made  in  the  right  linea 
semilunaris,  with  its  centre  over  the  lower  edge  of  the 
liver.  The  gall-bladder  was  completely  hidden  beneath 
the  edge  of  the  liver,  but  its  fundus  was  reached  and 
opened,  and  a  number  of  small  gall-stones  were  ex- 
tracted. On  now  passing  the  finger  along  the  bile-ducts 
beneath  the  liver,  a  large  mass  of  gall-stones  were  felt 
deep  under  the  liver,  which  could  only  just  be  reached. 
The  wound  was  now  enlarged  upwards  and  downwards, 
and  a  transverse  incision  made  across  to  the  middle 
line,  so  as  to  enable  the  lower  edge  of  the  greatly  en- 
larged liver  to  be  turned  up.  The  mass  of  stones  in  the 
right  hepatic  duct  could  now  be  reached  and  opened,  and 
with  very  considerable  difficulty  a  mass  of  large  gall-stones 
some  three  inches  in  length  and  over  an  inch  in  diameter  in 
places,  were  removed,  some  of  which  were  well  within  the 
liver  substance.  As  it  was  quite  impossible  at  such  a 
depth  to  bring  the  opening  in  the  duct  to  the  surface, 
and  as  the  patient  was  in  a  low  state,  a  glass  drainage-tube 
was  inserted  and  gauze  carefully  packed  around  it,  and 
the  wound  united  around  the  tube.  The  patient  suffered 
severely  from  shock,  rallied  somewhat  in  the  afternoon, 
but  was  much  troubled  by  coughing  up  mucus.  At  lo  in 
the  evening  he  was  easier  and  coughing  up  mucus  more 
easily.  However,  he  never  fully  rallied  from  the  shock  of 
the  prolonged  operation  and  died  at  5.30  a.  u. 

Necropsy. — The  same  morning  the  body  was  examined. 
There  were  already  good  adhesions  around  the  gauze 
packing  and  no  trace  of  leakage  of  discharge  into  the  peri- 
toneal cavity.  The  liver  was  removed  w4th  the  stom- 
ach and  duodenum  and  right  lung  altogether.  Only  one 
small  gall-stone  in  the  depth  of  the  liver  in  the  right  hepatic 


I 


Stones  in  the  Hepatic  Duct  i8i 

duct  was  found,  which  was  much  smaller  than  some  of 
those  removed  at  the  operation,  so  would  easily  have 
escaped  through  the  opening  made  in  the  duct,  and  would 
doubtless  have  escaped  through  the  wound,  although  too 
deep  in  the  liver  to  be  removed  at  the  operation.  Behind 
this  stone  the  bile-ducts  were  much  dilated  and  full  of  pus 
in  a  limited  portion  of  the  upper  posterior  portion  of  the 
right  lobe  of  the  liver.  This  tracking  abscess  had  opened 
posteriorly  by  the  side  of  the  inferior  vena  cava,  and 
travelled  up  through  the  diaphragm  and  the  base  of  the 
right  lung  into  the  inferior  bronchi.  The  common  bile- 
duct  was  dilated  and  its  opening  into  the  duodenum  was 
large  and  free. 


In  rare  instances  the  duct  behind  the  stone  may  rup- 
ture, as  in  the  following  case  recorded,  with  comments,  by 
John  Freeland,  M.R.C.S.  (Lancet,  May  6,  1882): 

Maria  J.,  a  black,  aged  sixty-five,  who  has  been  for 
many  years  troubled  with  intermittent  fever,  followed  by  a 
regular  train  of  symptoms,  commencing  with  vomiting, 
colicky  pains,  and  tenderness  of  the  abdomen,  and  ending 
with  jaundice,  more  or  less  severe,  applied  to  me  during 
one  of  these  attacks,  stating  that,  in  addition  to  her  gen- 
erally distressing  symptoms,  she  was  now  seized  with 
violent  and  excruciating  pain  in  the  stomach  and  chest, 
and  that  she  could  retain  nothing  whatever — water,  nour- 
ishment, or  medicines  being  immediately  rejected  with 
greatly  increased  suffering. 

On  examination  I  found  her  skin  hot  and  dry,  pulse 
hurried,  abdomen  fuller  than  natural,  and  in  some  parts 
painful  on  pressure.  She  says  she  has  been  taking  the 
medicines  I  generally  prescribed  during  these  seizures, 
but  has  not  obtained  the  relief  from  them  she  usually 
did  on  former  occasions,  and  was  quite  sure,  from  the  pain 


1 82        Special  Symptoms  in  Gall-stone  Disease 

and  excessive  prostration  she  now  felt,  that  there  was 
some  other  complaint  added  to  her  old  disease.  I 
immediately  prescribed  fifteen  drops  of  tincture  of  opium, 
with  a  little  sulphuric  ether,  and  applied  a  large  warm 
linseed  poultice  over  the  stomach  and  upper  part  of  the 
abdomen.  This  seemed  to  have  a  very  good  effect, 
for  the  pain  was  completely  subdued  after  a  second  dose, 
and  the  tenderness  of  the  abdomen,  which  was  so  evident 
at  the  time  of  my  first  examination,  was  now  almost 
entirely  gone;  the  warmth  of  skin,  although  somewhat 
subdued,  continued,  however;  and  as  there  was  now 
a  feeling  of  headache  and  nausea,  which  prevented  my 
patient  from  expressing  herself  as  much  relieved,  as  I 
expected  she  would  have  been  after  having  suffered  so 
intensely  some  hours  before,  I  ordered  a  mixture  of 
carbonate  of  soda  and  nux  vomica  in  small  doses,  and 
desired  her  to  report  at  once  in  case  the  pain  should  re- 
turn. During  the  next  night  she  was  suddenly  seized 
again  with  acute  pain,  but  was  as  readily  and  easily 
relieved  by  the  opiate,  ether,  and  poultice,  as  in  the  pre- 
vious instance.  Her  relief,  however,  was  of  short  dura- 
tion, for  the  pain  soon  returned  with  increased  severity, 
and  was  now  accompanied  with  a  somewhat  tympanitic 
and  extremely  tender  abdomen.  I  at  once  ordered  pills 
of  calomel  and  opium,  to  be  administered  every  second 
hour,  and  the  poultice  to  be  continued,  with  the  addition 
of  spirits  of  turpentine  freely  sprinkled  over  it.  On  my 
next  visit,  in  about  six  hours  afterwards,  I  found  the 
extremities  cold,  pulse  120  and  small,  and  the  body 
generally  covered  with  a  clammy  sweat;  the  pain  in  the 
abdomen  had  ceased,  but  the  vomiting  returned  at  in- 
tervals, with  great  depression,  until  she  died  in  about 
eight  hours  afterwards. 

On  examination  of  the  body  almost  immediately  after 
death,  the  cavity  of  the  abdomen  was  found  literally  filled 
with  blood  and  bile,  the  intestines  gangrenous  in  spots. 


Stones  in  the  Hepatic  Duct  183 

and  here  and  there  highly  inflamed  and  congested ; 
the  peritoneum  one  mass  of  inflammatory  deposit  and 
adhesions,  the  Hver  and  gall-bladder  healthy;  the  latter 
appeared,  however,  smaller  than  natural,  and  was 
entirely  empty,  and  the  spleen,  which  was  of  a  bright 
orange  tint,  was  so  deeply  stained  with  bile  that  even 
when  removed,  washed,  and  broken  up  in  pieces,  the 
bright  colour  remained  and  appeared  to  be  so  intimately 
mixed  up  in  its  stricture  that  it  was  quite  impossible 
to  lessen  it.  The  hepatic  duct  was  found  lacerated,  and 
the  opening  in  this  through  which  the  bile  had  escaped 
appeared  but  recently  formed,  but  the  calibre  of  the 
duct  was  much  larger  and  its  length  greater  than  usual, 
and  in  some  places  distended  into  pouches  or  bags  which 
contained  gall-stones  varying  in  size  from  a  pea  to  a 
strawberry.  In  one  of  these  pouches  or  bags  a  most 
remarkable  appearance  presented  itself  in  the  form 
of  a  slit  or  opening,  which  was  fully  occupied  and  oc- 
cluded by  the  point  or  apex  of  one  of  these  stones.  On 
displacing  and  replacing  the  stone  in  its  position  (which 
was  most  readily  effected  by  the  mere  disturbance  of  the 
parts),  I  discovered  that  the  slit  which  it  had  occupied 
was  as  completely  and  naturally  formed  as  if  it  had  been 
the  normal  state  of  the  duct,  the  edges  being  firm,  smooth, 
and  slightly  everted;  and  although  this  stone  must  at 
some  time  or  another  have  caused  ulceration  by  its 
pressure  and  given  rise  to  grave  symptoms,  there  is  no 
doubt  in  my  mind  that  it  afterwards  acted  as  a  plug, 
and  so  effectually  sealed  the  aperture  in  the  duct  (so 
long  as  it  remained  in  situ)  that  no  bile  escaped  into 
the  cavity  of  the  abdomen  except  at  times,  and  in  such 
minute  quantities  as  only  to  give  rise  to  those  slight 
attacks  and  symptoms  which  I  already  mentioned  as 
having  been  of  frequent  occurrence  during  the  usual 
intermittent  fevers  which  my  patient  more  or  less  an- 
nually passed  through. 


184       Special  Symptoms  in  Gall-stone  Disease 

Now  it  is  evident,  I  think,  that  the  second  or  recent 
rupture  in  the  duct,  which  was  quite  patulous  and 
surrounded  with  coagula,  was  the  immediate  cause  of 
death,  and  that  the  first  or  older  opening  existed  for  years 
and  had  been  nearly  always  occupied  and  closed  by  the 
presence  of  the  gall-stone  which  only  occasionally  al- 
lowed the  bile  to  escape  when  from  some  particular 
exertion  or  vomiting  it  became  temporarily  displaced. 


(D)  STONE  IN  THE  COMMON  DUCT. 
Obstruction  of  the  common  duct  by  a  gall-stone  or 
several  stones  may  be  complete  or  incomplete.  A  single 
stone  may  be  so  tightly  wedged  in  the  duct  that  no  drop 
of  bile  can  pass  by  it,  or,  on  the  other  hand,  it  may  fit 
so  loosely  that  bile  may,  from  time  to  time,  flow  past  it 
readily.  Courvoisier,  in  1 23  cases,  found  that  the  position 
of  the  stone  or  stones  blocking  the  common  duct  was  as 
follows : 

In  17  cases  at  the  commencement  of  the  duct. 

In  19  cases  in  the  middle  of  the  duct. 

In  20  cases  near  the  duodenum  (retroduodenal  portion). 

In  41  cases  at  the  ampulla. 

In  26  cases  the  whole  length  of  the  duct  was  blocked. 

In  cases  recorded  by  Cruveilhier  and  Frerichs,  the  whole 
length  of  the  bile  passages,  including  all  the  intra-hepatic 
ducts,  was  blocked  by  an  infinite  number  of  fine  stones 
and  sand. 

I.  Complete  occlusion  of  the  duct  is  rare.  It  results 
more  often  from  growth  or  stricture  in  the  duct  or  com- 
pression   of    the  duct  from  without  than  from    stone. 


Fig.   44. — Dilatation  of  the  intra-hepatic  ducts  (Cruveilhier). 


i 


Partial  Occlusion  of   the  Duct  185 

A  stone  producing  complete  blockage  of  the  duct  may 
lie  wholly  in  the  common  duct  or  may  be  extruded  into 
the  lumen  from  the  cystic  duct.  In  the  latter  condi- 
tion there  is  always  an  immense  thickening  of  the  ducts, 
the  wall  of  the  cystic  duct  in  one  specimen  in  my  posses- 
sion measuring  nearly  an  inch  in  thickness.  In  all  cases 
where  the  block  is  complete  the  bile  pent  up  behind 
the  stone  becomes  gradually  absorbed  and  the  hepatic 
ducts  become  filled  with  clear,  sticky  mucus,  and  are 
everywhere    greatly   dilated. 

The  chief,  and  often  the  sole,  symptom  of  complete 
occlusion  of  the  common  duct  is  deep  and  unvarying 
jaundice.  Pain  may  be  present  in  the  earliest  stages, 
but  it  is  rarely  or  never  severe  and  speedily  disappears. 
There  is  no  distension  of  the  gall-bladder,  and  the  signs 
and  symptoms  of  septic  infection,  which  are  such  con- 
stant features  of  partial  occlusion  of  the  common  duct, 
are  entirely  absent.  It  is  often  a  matter  of  the  greatest 
difficulty  to  distinguish  this  form  of  disease  clinically 
from  malignant  disease  of  the  ducts  or  of  the  head  of 
the  pancreas.  The  early  history  of  pain  and  colic  and 
the  absence  of  enlargement  of  the  gall-bladder  are  the 
most  helpful  points. 

2.  Partial  Occlusion  of  the  Duct. — In  the  very  great 
majority  of  cases  of  obstruction  of  the  common  duct  by 
stone  the  block  is  only  a  partial  and  an  intermittent  one. 
When  the  stone  has  become  fixed,  a  dilatation  of  the  duct 
behind  the  obstruction  always  occurs.  In  this  dilated 
duct  the  stone  is  free  to  move.  It  then  forms  a  ball- 
valve,  as  was  pointed  out  by  Fenger,  at  times  blocking 
the  duct  absolutely,  at  other  times  allowing  bile  to  pass 


i86        Special  Symptoms  in  Gall-stone  Disease 

it  unimpeded.  A  ball- valve  stone  may  be  found  at  any 
part  of  the  duct,  but  is  more  commonly  found  in  the 
ampulla  of  Vater.  If  one  stone  is  found  to  be  blocking 
the  duct,  other  stones  will  often  be  discovered.  In- 
deed, obstruction  of  the  common  duct  is  far  more  often 
due  to  many  stones  than  fo  one.  If  a  stone  be  found  in 
the  first  portion  of  the  duct,  another  may  be  felt  in  the 
ampulla,  or  the  whole  length  of  the  duct  even  may  be 
tightly  packed  with  a  multitude  of  large  and  small 
calculi.  In  other  cases  stones  may  be  found  in  the  com- 
mon duct  and  in  the  hepatic  ducts.  Xo  operation  can  be 
considered  as  complete  which  does  not  include  a  verv^ 
careful  examination  of  other  parts  of  the  bile-duct  than 
that  in  which  a  large,  apparently  single  stone  is  found. 
If  possible,  an  exploration  of  the  duct  should  be  effected 
with  the  finger  rather  than  with  a  spoon  or  probe.  In 
this  way  only  can  it  be  made  certain  that  the  ducts  are 
clear. 

The  statement  that  it  is  the  rule  to  find  multiple  calculi 
in  the  duct,  rather  than  a  single  stone,  is  at  variance  with 
the  statistics  of  Courvoisier,  and  almost  all  other  authori- 
ties. In  the  cases  that  come  to  the  care  of  a  surgeon 
there  can  be  no  doubt  whatever  of  its  truth. 

As  a  rule,  the  lower  down  in  the  duct  a  calculus  is 
foimd,  the  smaller  is  it.  Those  blocked  in  the  ampulla 
are  approximately  the  size  of  a  split  pea.  Those  in  the 
upper  part  of  the  duct  may  be  as  large  as  a  nutmeg. 

The  ducts  behind  a  calculus  are  generally  dilated  to  a 
moderate  degree :  to  a  degree  almost  always  that  will 
permit  of  the  forefinger  being  passed  along  them.  In 
some  cases  the  dilatation  may  be   phenomenal,  and  in 


Partial   Occlusion   of   the   Duct  187 


Fig  45, — -Biliary  obstruction;  cholecystenterostomy.  The  com- 
mon bile-duct  was  occluded  by  a  black  calculus  three-fourths  of  an 
inch  in  diameter,  and  reaching  to  within  an  inch  of  the  papilla.  The 
stone  shews  a  bifurcation  corresponding  to  the  junction  of  the  cystic 
with  the  main  hepatic  duct,  both  of  which  are  thus  partially  obstructed. 
The  gall-bladder  and  cystic  duct  are  both  dilated,  as  also  the  hepatic 
ducts  throughout  the  liver.  Just  beyond  the  line  of  suture  in  the 
small  intestine  is  seen  a  perforation  (red  rod).  From  a  man,  aged 
forty-one,  who  was  admitted  for  enlargement  of  the  liver  and  spleen, 
with  jaundice,  from  occasional  attacks  of  which  he  had  suffered  for 
fourteen  years.  On  exploration  it  was  found  impossible  to  remove 
gall-stones.  An  anastomosis  was  established  between  the  fundus  of 
the  gall-bladder  and  the  jejunum.  After  death,  general  Suppurative 
peritonitis  was  found.  The  left  pleural  cavity  contained  some 
sero-purulent  fluid;  the  spleen  weighed  53  ounces  (Guy's  Hospital 
Museum,  No.   1422). 


1 88        Special  Symptoms  in  Gall-stone  Disease 

more  than  one  recorded  case  the  tumour  formed  has  been 
recognised  on  palpation  of  the  abdomen  and  has  been 
mistaken  for  a  dilated  gall-bladder.  In  one  case  (Guy's 
Hospital  Museum,  No.  1419)  the  dilated  common  duct 
had  formed  a  thick- walled  cyst  six  inches  in  diameter. 
The  obstruction  was  valvular.  Terrier  has  recorded 
three  cases  in  w^hich  a  dilated  duct  was  mistaken  for  a 
pancreatic  cyst,  a  hydatid  of  the  liver,  and  a  distended 
gall-bladder,  respectively.  In  many  cases  the  duct 
beyond  the  impacted  stone  is  dilated  also,  but  it  may  be 
found  narrowed,  or  even,  it  is  said,  quite  obliterated. 
The  wall  of  the  dilated  duct  consists  almost  entirely  of 
fibrous  tissue,  the  mucosa  being  thin  and  atrophied.  The 
fluid  contained  within  the  duct  is  always  deeply  tinged 
with  bile,  and  in  fact  consists  of  bile  with  an  added 
quantity  of  mucus.  In  accordance  with  Courvoisier's 
observation,  it  is  now  generally  recognised  that  in  cal- 
culus obstruction  to  the  common  duct  there  is  rarely 
an}^  distension  of  the  gall-bladder.  On  the  contrary, 
the  gall-bladder  is  found  shrivelled,  thickened,  and  em- 
bedded deeply  in  dense  adhesions,  in  the  great  majority 
of  cases. 

The  symptoms  of  stone  in  the  common  duct  are  some- 
times trivial  and  inconspicuous,  and  indeed  are  at  times 
entirely  absent.  I  have  twice  found,  during  the  per- 
formance of  cholecystotomy,  that  stones  were  present 
in  the  common  duct  when  symptoms  were  wholly  lacking. 
If  the  stone  is  small,  or  fits  loosely  in  the  duct,  there  may 
be  neither  obstruction  nor  cholangitis,  and  the  stone, 
therefore,  may  never  attract  clinical  recognition. 

The  symptoms  are  due,   in  part,   to   the  mechanical 


1 


Partial  Occlusion  of  the  Duct  189 

impediment  in  the  duct ;  in  part,  to  the  cholangitis  which 
the  stones  excite. 

Pain  is  present  only  at  times.  It  comes,  as  a  rule,  in 
attacks,  which  vary  much  in  severity.  The  pain  is  dull 
and  aching,  with,  especially  in  the  beginning  of  the 
attack,  spasmodic  outbursts.  As  a  rule,  the  pain  is 
accompanied  by  a  rigor;  the  temperature  runs  rapidly 
up  to  102°,  103°,  or  104°;  there  are  shivering  and  collapse, 
followed  by  sweating,  and  in  the  succeeding  hours  it  is 
noticed  that  the  jaundice,  which  is  persistent,  has  deep- 
ened much  in  tinge.  In  the  intervals  between  such 
attacks  as  these  the  patient  suffers  little  or  not  at  all. 
There  is  neither  pain  nor  tenderness  over  the  liver,  and 
the  jaundice  grows  gradually  paler.  Jaundice,  which 
was  described  by  Courvoisier  as  the  ' '  cardinal  symptom ' ' 
of  common  duct  obstruction,  never  disappears,  though 
in  very  old-standing  cases  the  patients  may  say  that  they 
are  free  from  jaundice,  when  there  is  still  an  obvious 
tinge  of  yellow  in  the  conjunctivae  and  in  the  skin.  In 
one  patient,  a  lady,  who  had  suffered  from  these  ague- 
like paroxysms  for  nine  years,  the  skin  was  said  to  be 
"sallow"  normally,  and  the  suggestion  that  she  was 
jaundiced  to  a  slight  degree  met  with  no  confirmation. 
It  was  only  after  the  removal  of  one  large  and  several 
stones  from  the  common  duct  that  the  'patient  became 
convinced,  as  her  skin  gradually  whitened,  that  the 
sallowness  was  due  to  jaundice  from  which  she  had  never 
been  free  through  all  the  nine  years.  Many  patients 
notice  that  the  jaundice  varies  during  the  course  of  the 
day,  being  lighter  in  the  morning  and  becoming  deeper 
towards  night. 


190       Special  Symptoms  in  Gall-stone  Disease 

I  have,  on  two  occasions,  found  stones  in  the  common 
duct  when  no  symptoms  were  present.  Kehr  has  said 
that  jaundice  is  absent  in  one-third  of  his  cases  of  stone  in 
the  hepatic  and  common  ducts,  an  experience  that  is 
almost  certainly  fallacious.     In  over  one   hundred   con- 


Time 

ME 

M  E 

M  E 

MEM 

E  M  E  M  E 

M  E 

M  EM  EM  E,M  EM  E|M 

E   M  E  M 

E  M  E 

m'e 

MEM 

E  M  E 

Unne 

[ 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

■ 

1 

j 

. 

1 

1 

i 

r-iZ" 

107° 
106» 
105' 

-^ 



~ 

— 

—  ^ 

-— 

_J_ 

i- 

-J- 

— 

-  -J 

^-1.. 

-j— 

-4^—. 

--r 

: 

^' 

-'- 

-^ 

--\- 

-f- 

—J 

^ 

- 

t-- 

__  ...4 

H~ 

-4- 

^      -i 

i   - 

- 

^4- 

Zj- 

— 

"=|r 

rt 

-l- 

-r- 

- 

z] 

_ 

- 

r 

zi 

— 

-4Z 

. — h 

H-i+- 

-U" 

— 1--- 
-■ t- 

'SZZ 

~<r- 

-. 

^^ 

„__,. 

-;- 

— i— 

- 

z 

z 

z  z 

T^-- 

~i 

*3TJ 

: 

--i- 

4^ 

'\- 

r 

-- 1~ 

ZZ 

—\~ 

- 

z 

- 

; 

z 

][-+   1 

l-A 

z!zr 

izjz 

■ 

^ 

~ 

- 

=t 

- 

E^ 

- 

Z" 

z 

- 

zlz 

z 

-^ 

[-■ 

- 

z 

._._ 

1  -T' 

-T 

zzz 

zz^_  _ , 

Ii: 

llOS" 

1 

^  102° 

4  101° 
100° 
99° 

__ 

_ 

-4— 



_ 

„ 

1 



_ 

1 

- 



1  -._ 

. 



1  "*' 

Tt: 

z 

- 

--t- 

J— 

-n 

r;r 



— 

- 

z" 

p 

Zj 

tz 

z 

z 

t  z. 

1     • 

' 

!    ■ 

■ 

----■ 

— i — 

-f- ^ 

-+- 

— L- 

^ 

— 

— 

H 

— 

^- 

-- 

-  * 

t  • 

1       ' 

1        , 

. 

't 

— 1" 

'■p- 

-^ — 

M 

_l_ 

z 

z 

;^ 

z 

=f 

ZfZ 

. 

ft   1 

: 

-- 

~ 

i  _i_ 

^ 

= 

E 

= 

jj 

E]E 

i 
H — 

-^' 

-~r 

4 

-39- 

^ 

4^ 

=F 

:-t:r 

y 

~^ 

5 

= 

E 

£ 

iz 

I 

=^ 

-4-  - 

~-   -Z^ 

r- 
1  - 

z: 

„L 

:  r 

— 

•^^ 

-\ 

K 

f 

"f 

--- 

j^ 

Zf" 

t 

1 

"'.  1 

-  i 

■  4—1 

I 

,E 

1 

4--  ■) 

-^  -4^ 

:  i 
:  ! 

-37- 

97° 

D<jofD\M 
raise 

g 

1 

-  h 

1 

Liz 

- 

i 

y' 

¥ 

1 

n — ' 

Nj 

1 

1 — M 

'  '^t- 

:zz^ 

-36° 

1 

' 



-L 

j 

1 

— 1— 

-A- 

J 

. 

— f— 

— •— 

-4— 

—1 — 

r 

—<~ 

-r^ 

— ^- 

^_ 

=Th 

1 

1 

" 

- 

-V 

■^-^ 

\ 

^  -._. 

'-  . 

-■ 

V,            X        ^ 

V    \ 

\ 

\\ 

X    ^~ 

- 

R.sp. 

•^ 

\ 

x\ 

^^ 

X      ~  .      ■ 

•.  X 

^  \ 

V  \ 

■^55° 

Datt 

1 

Fig.   46. — The  "  steeple"  chart  in  a  case  of  stone  in  the  common  duct. 


secutive  operations  for  gall-stones  I  have  never  failed  to 
examine  with  scrupulous  care  the  whole  length  of  the 
hepatic  and  common  ducts,  and  the  two  instances 
mentioned  are  the  only  ones  I  have  met  with. 

The  temperature  angle  in  an  attack  is  of  the  character- 
istic "steeple"  form — there  is  a  rapid  rise   and  a   rapid 


Partial  Occlusion  of   the  Duct  191 

fall  to  the  normal  in  each  attack.  Temperature  elevation 
is  much  more  often  present  in  common  duct  obstruction 
when  a  stone  is  the  obstructing  agent  than  when  growth 
or  any  other  form  of  blockage  exists. 

Courvoisier,  in  his  analysis  of  recorded  cases,  found 
fever  in  25  per  cent,  of  the  cases  of  occlusion  from  stone, 
and  in  only  10  per  cent,  of  the  cases  of  occlusion  due  to 
other  causes.  The  former  estimate  seems  to  me  to  be 
considerably  below  the  truth.  If  a  case  of  common  duct 
obstruction  be  observed  for  a  period  of  two  or  three  weeks, 
there  will,  with  few  exceptions,  be  found  some  abrupt 
elevation  of  temperature  coinciding  with  the  pain,  and 
attacks  of  shivering  and  subsequent  sweating,  not  of 
sufficient  gravity  to  be  considered  as  rigors,  will  occur. 

During  an  attack,  and  for  some  hours  after,  there  may 
be  a  slight  enlargement  of  the  liver,  and  the  liver  every- 
where is  tender  to  the  touch. 

In  chronic  obstruction  of  the  common  duct  the  liver 
is  always  enlarged  in  the  earlier  stages;  its  increase  in 
size  may  indeed  be  considerable.  The  liver  may  reach 
the  umbilicus,  or  even  descend  beyond  it.  In  each 
attack,  when  a  rigor  and  an  elevation  of  temperature, 
followed  by  a  deepening  of  the  jaundice,  occur,  an  in- 
crease in  the  size  of  the  liver  may  be  observed,  and  the 
organ  on  handling  is  found  to  be  tender.  In  the  latter 
stages  the  liver  decreases  slowly  in  size,  and  at  the  last 
may  be  even  smaller  than  the  normal.  According  to 
Mongourt,  the  shrinkage  of  the  liver  is  the  most  impor- 
tant sign  of  the  degeneration  of  the  hepatic  cells. 

The  condition  of  the  stools  and  of  the  urine  varies  from 
time  to  time.     As  a  rule,  some  bile  passes  always  into  the 


192        Special  Symptoms  in  Gall-stone  Disease 

intestine,  so  that  the  motions  are  a  deep  buff  in  colour. 
After  an  attack  there  is  obvious  evidence,  both  in  the 
faeces  and  in  the  urine,  that  less  bile  is  getting  access 
to  the  duodenum.  The  variations  are,  however,  much 
more  readily  recognised  in  the  stools  than  in  the  urine. 
The  persistent  presence  of  urobilin  in  the  urine  is  held 
by  many  observers  to  indicate  the  onset  and  the  con- 
tinuance of  a  process  damaging  to  the  hepatic  cells.  In 
many  cases  an  enlargement  of  the  spleen  is  noticed,  more 
especially  after  an  attack  and  for  some  days  subse- 
quently. 

The  gastric  disturbances  noticed  in  cases  of  gall-stone 
impaction  vary  within  very  wide  limits.  There  may  be 
nothing  more  than  a  sense  of  uneasiness  in  the  epigastrium 
and  distension  after  food,  for  which  there  is  often  a  dis- 
taste, or,  on  the  other  hand,  there  may  be  severe  vomiting 
during  and  subsequent  to  the  attack  and  a  feeling  of  pro- 
found nausea.  Itching  of  the  skin  is  almost  constant, 
as  in  all  forms  of  jaundice,  and  symptoms  of  boils  may 
at  times  be  noticed. 

One  of  the  most  marked  and  characteristic  symptoms 
of  obstruction  of  the  common  duct  by  stone  is  loss  of 
weight.  A  loss  of  two,  three,  or  four  stone  is  not  infre- 
quently recorded.  The  loss  is  both  rapid  and  consid- 
erable, and  after  a  successful  operation  is  very  speedily 
regained.  This  loss  of  weight  was  ascribed  by  Fenger 
to  "intermittent,  frequent,  ptomaine  intoxication, — 
that  is  bile-absorption, — as  well  as  to  disturbed  di- 
gestion." It  is  most  important  that  this  symptom 
should  be  recognised  as  a  frequent  and  striking  mani- 
festation of  stone  in  the  common  duct,  for  the  haggard, 


Partial   Occlusion   of   the   Duct 


19: 


wasted,  often  emaciated  appearance  of  the  patient  may 
strongly  suggest  a  diagnosis  of  malignant  disease.     It 


Fig.  47. — -Impaction  of  a  large  oval  calculus  in  the  extremity  of  the 
common  bile-duct,  a  portion  of  the  stone  projecting  into  the  duode- 
num. The  patient  was  a  very  large  woman,  seventy  years  of  age 
For  nearly  six  months  before  death  she  had  been  subject  to  spasmodic 
pains  at  the  stomach,  which  came  on  with  shivering,  like  an  ague  fit, 
continued  from  half  an  hour  to  an  hour,  and  were  succeeded  by 
unnatural  heat.  To  these  were  added  in  the  last  month  of  life 
frequent  vomiting,  great  thirst,  and  a  deep  jaundice  colour  of  the 
skin.  Three  days  before  death  she  was  suddenly  seized  with  un- 
usually severe  shivering  and  pain,  which  extended  quite  round  the 
abdomen,  and  continued  without  remission  until  her  death.  The 
liver  after  death  was  found  pale,  soft,  and  fragile.  The  gall-bladder 
contained  numerous  small  angular  calculi;  both  it  and  all  the  bile- 
ducts  were  distended,  and  all  their  coats  were  greatly  thickened  ;  the 
stomach  appeared  healthy  (Royal  College  of  Surgeons'  Museum,  No. 
2826). 


is  more  than  likely  that  some  measure  of  responsibility 
for  this  symptom  mav  rest  with   the   pancreas,   whose 
^3 


194       Special  Symptoms  in  Gall-stone  Disease 

secretion  may  be  profoundly  modified  both  in  quality 
and  in  quantity  by  an  extension  of  the  inflammation 
from  the  common  duct  to  the  canal  of  Wirsung  into  the 
substance  of  the  pancreas.  Chronic  pancreatitis  is  by 
no  means  an  uncommon  event  in  long-standing  ob- 
struction of  the  common  duct,  wherever  the  obstruction 
may  be. 

The  characteristic  signs  and  symptoms  of  stone  in  the 
common  duct,  therefore,  are :  Persisting  jaundice,  which 
alters  considerably  in  depth  of  tinge,  varying  between 
morning  and  night,  becoming  markedly  deeper  after  an 
attack  of  pain  and  gradually  lessening  in  the  intervals. 
The  jaundice  may  be  said  to  ebb  and  flow.  Pain  which 
comes  on  in  "attacks."  The  pain  is  diffused  over  the 
whole  hepatic  area,  is  constant,  and  is  liable  to  acute 
exacerbations.  During  an  exacerbation  there  is  a  rigor, 
and  a  temperature  of  103°  or  104°  is  quickly  reached,  and 
nausea  and  vomiting  are  present.  During  and  after  an 
attack  there  are  tenderness  and  enlargement  of  the  liver, 
and  probably  also  of  the  spleen.  Bile  enters  the  in- 
testine in  small  quantities,  as  a  rule ;  but  after  a  paroxysm 
the  quantity,  as  shewn  by  alterations  in  the  urine  and  the 
faeces,  is  lessened.  Itching  of  the  skin  is  always  present. 
There  is  rarelv  anv  enlargement  of  the  gall-bladder,  and 
ascites  is  absent,  unless,  as  very  rarely  happens,  there 
is  pressure  upon  the  portal  vein.  The  paroxysms  are 
ague-like  in  character  and  may  occur  with  remarkable 
regularity.  Osier  has  attempted  to  associate  a  special 
symptom  group  with  ball-valve  stone,  which  is  most 
commonly  found  in  the  ampulla  of  \''ater. 


Partial   Occlusion   of   the   Duct  195 

"(a)  Ague-like  paroxysms,  chills,  fever,  and  sweating; 
the  hepatic  intermittent  fever  of  Charcot. 

"  (b)  Jaundice  of  varying  intensity  which  persists  for 
months  or  even  years  and  deepens  after  each  paroxysm. 

"  (c)  At  the  time  of  the  paroxysms,  pains  in  the  region 
of  the  liver,  with  gastric  disturbances." 

The  cause  of  the  attacks  is  probably  to  be  found  in  a 
renewed  attempt  on  the  part  of  the  duct  to  expel  the 
stone.  From  the  dilated  portion  of  the  duct  the  stone 
is  made  to  enter  the  narrow  portion,  and  a  spasmodic 
muscular  contraction  is  set  up.  In  this  wav  a  fresh 
damage  is  done  to  the  duct,  tension  is  increased,  infection 
occurs,  a  cholangitis,  or  an  increase  of  an  inflammatory 
condition  already  in  existence,  takes  place,  and  the 
mucosa  throughout  the  ducts  swells  and  narrows  the 
lumen.  The  obstruction,  in  fact,  becomes  for  the  time 
mechanically  complete,  and  partly  for  this  reason, 
partly  because  of  the  renewed  attack  of  cholangitis, 
the  jaundice  deepens.  It  is  doubtful  if  an  infective 
process  once  set  up  in  the  common  duct  ever  disappears 
unless  the  obstructing  agent  is  removed.  There  is  al- 
ways retention  of  bile  behind  the  stone,  and  therefore 
a  ready  opportunity  for  the  constant  proliferation  of 
organisms. 

The  existence  of  cholangitis  is  shewn  by  the  presence 
of  jaundice  and  of  fever.  If  a  stone  be  lodged  in  the 
common  duct  and  neither  of  these  be  present,  it  may  be 
taken  that  cholangitis  does  not  exist,  and  that  the  bile 
is  free  from  organisms. 

In  the  most  severe  forms  of  infection  suppuration  may 
arise  in  the  duct.     It  is  certain  that  infection  is  present 


196        Special  Symptoms  in  Gall-stone  Disease 

in  all  cases  attended  by  the  symptoms  just  enumerated; 
it  is  equally  certain  that  the  infection  rarely  gives  rise  to 
suppuration.  When  a  stone  is  removed  from  the  common 
duct,  even  when  jaundice  is  marked  and  long-enduring, 
it  is,  in  my  experience,  very  rare  to  find  pus  in  the  ducts, 
however  severe  the  clinical  manifestations  may  have 
been.  Some  authors,  Kehr  and  others,  talk  of  fetid  pus 
as  being  not  uncommonly  found  behind  a  stone  in  the 
common  duct.     In  my  experience  it  is  almost  unknown. 

A  suppurative  cholangitis,  therefore,  is  a  rare  com- 
plication of  impacted  stone.  It  is  also  a  most  serious, 
often  indeed  a  lethal,  one.  The  suppuration  may  ex- 
tend not  only  along  the  whole  length  of  the  common  duct, 
but  also  may  involve  the  cystic  duct  and  the  gall-bladder 
(giving  rise  to  empyema)  and  the  hepatic  ducts.  In  some 
cases  an  abscess  or  abscesses  may  develop  in  the  liver 
by  direct  extension  of  the  infection  along  the  ducts.  In 
cases  of  multiple  abscesses  the  symptoms  are  those 
of  profound  septic  poisoning.  The  temperature  remains 
high,  losing  its  "steeple"  projections,  rigors  may  occur 
frequently,  and  the  general  health  and  strength  of  the 
patient  are  rapidly  enfeebled.  There  may  be  signs  of 
peritonitis  over  and  around  the  liver  and  fluid  may  be 
found  in  the  right  pleura.  There  may  be  a  subphrenic 
abscess.     The   spleen  becomes  larger  and  very   tender. 

When  the  abscess  is  localised,  a  swelling  on  the  surface 
of  the  liver  may  be  palpable.  This  is  tender  to  the  touch, 
especially,  as  Xaunyn  and  Osier  point  out,  during  the 
hours  that  succeed  a  rigor.  The  jaundice  is  not  so  deep, 
nor  are  the  variations  so  noticeable.  The  clinical  present- 
ment is,  it  will  be  seen,  one  of  a  severe  septiccemia,  ac- 


Partial   Occlusion   of   the   Duct  197 

companied  by  signs  of  intense  inflammation  in  the  gall- 
ducts. 

A  gall-stone  may  remain  in  the  common  duct  for  years. 
In  one  of  my  patients  the  symptoms  had  been  present 
for  nine  years.  One  of  the  consequences  of  so  long- 
enduring  an  inflammation  in  the  duct  is  that  the  head  of 
the  pancreas  may  be  involved  by  infection  of  Wirsung's 
duct,  or,  perhaps,  by  direct  or  by  lymphatic  infection. 
Chronic  pancreatitis,  as  was  pointed  out  by  Riedel,  is  a 
not  infrequent  complication  of  gall-stones  impacted  in 
the  common  duct.  Opie  has  shewn  that  in  all  probabil- 
ity many  cases  of  acute  pancreatitis  are  due  to  the  im- 
paction of  a  stone  of  small  size  in  the  ampulla  of  Vater. 
In  such  a  case  the  symptoms  come  on  with  marked  sudden- 
ness. They  are  epigastric  pain  and  tenderness,  followed 
by  distension,  vomiting,  and  collapse.  The  diagnosis 
most  often  made  is  one  of  intestinal  obstruction.  In 
acute  pancreatitis,  with  fat  necrosis,  there  is  no  in- 
creased leucocytosis ;  in  acute  infective  cholangitis  there 
is  a  marked  leucocytosis. 

The  following  are  a  few  cases  selected  from  a  large 
number  upon  which  I  have  operated : 

Stone  in  Common  Duct:  Duodeno-choledochotomy. — M. 
A.  R.,  female,  aged  forty-one,  admitted  March  23,  1901, 
with  jaundice.  For  eight  or  nine  years  has  been  sub- 
ject to  attacks  of  pain  in  the  right  hypochondriac 
region,  and  pain  after  food  in  the  epigastrium  and  "right 
round  the  body."  Sixteen  months  ago  for  the  first  time 
an  attack  was  followed  by  jaundice.  The  pain  came 
suddenly  and  overwhelmed  her.  She  was  in  bed  with 
pain   and   soreness   for   three   days.     On   the   third   day 


198        Special  Symptoms  in  Gall-stone  Disease 

jaundice  was  observed.  Four  months  ago  a  similar 
attack,  and  since  then  five  attacks  similar  in  character, 
but  varying  in  intensity.  She  was  deeply  jaundiced 
four  months  ago  and  has  been  jaundiced  since,  though  the 
depth  of  colour  has  varied  very  much.  When  the  last 
attacks  have  commenced,  she  has  felt  cold  and  shivery, 
and  in  a  few  minutes  she  has  broken  out  into  profuse 
sweats.  Nothing  to  be  felt  in  the  abdomen.  On  opening 
the  abdomen  the  gall-bladder  was  found  shrunken  and 
thickened ;  it  was  freed  from  adhesions,  opened,  and  seven 
stones  removed.  A  large  stone  was  felt  in  the  ampulla 
of  Vater;  an  attempt  to  push  it  back  into  the  common 
duct  failing,  the  duodenum  was  opened  and  the  ampulla 
incised  and  the  stone  removed.  The  duodenum  was 
closed  and  the  gall-bladder  drained.  The  patient  was 
discharged  well  on  April  23,   1901. 

Stone  in  Common  Duct:  Choledochotomy.—^l.  A.  C, 
female,  aged  thirty-three,  admitted  with  deep  jaundice 
January  11,  1899.  In  May,  1899,  she  had  an  attack 
of  pain  in  the  region  of  the  xiphisternum,  passing  round 
the  right  side  to  the  scapula.  The  pain  was  very  severe, 
produced  faintness  and  collapse,  and  was  accompanied 
and  followed  by  vomiting.  Jaundice  followed  two  or 
three  days  later.  Several  similar  though  slighter  at- 
tacks since.  For  eight  weeks  has  not  been  free  from 
jaundice,  though  there  has  been  considerable  variation 
in  its  tinge.  Each  attack  has  caused  profuse  sweat- 
ing. 

On  November  7th  the  abdomen  was  opened.  The 
pyloric  end  of  the  stomach  was  found  to  be  embedded  in 
adhesions  with  the  under  surface  of  the  liver  and  gall- 
bladder. After  freeing  the  bladder  and  ducts  two  stones 
were  felt  in  the  common  duct:  one  was  crushed  and 
passed  onwards  into  the  abdomen,  the  other  was  fixed  and 
was  removed  through  an  incision  in  the  duct;  it  was  of 
the  size  of  a  small  Barcelona  nut.     The  duct  was  stitched 


Partial   Occlusion  of   the   Duct  199 

and  a  Bantock's  tube  introduced.  The  patient  was  dis- 
charged well  on  December  3d. 

Stones  in  Common  Duct:  Choledodiotomy. — C.  W.,  fe- 
male, aged  forty-two,  admitted  March  7,  1900.  Patient 
admitted  with  jaundice.  For  several  years  has  had 
occasional  attacks  of  "spasms,"  followed  by  slight 
jaundice.  No  attack  has  lasted  more  than  a  few  hours, 
and  has  never  incapacitated  her  for  more  than  a  day, 
or  perhaps  two,  from  her  work  until  five  months  ago, 
when  she  had  a  severe  attack,  followed  by  jaundice. 
Pain  and  jaundice  have  been  present  ever  since,  varying 
in  intensity,  but  never  very  severe.  During  the  last  few 
weeks  has  felt  cold,  and  shivered  when  an  attack  was 
impending;  soon  afterwards  has  sweated  profusely. 
The  motions  have  been  very  pale  for  five  months  and  the 
urine  high-coloured. 

At  the  operation  a  small,  thick,  adherent  gall-bladder 
was  opened  and  relieved  of  forty-six  stones  which  lay 
within  it  and  the  cystic  duct.  The  common  duct  had 
seven  small  stones  in  it ;  these  were  removed  by  a  separate 
incision,  which  was  stitched  up  directly.  The  gall- 
bladder was  drained.  The  patient  was  discharged,  quite 
well,  on  March  31st. 

Stone  in  Common  Duct:  CholedocJiotouiy. — ^Irs.  G., 
aged  fifty-eight,  admitted  June,  igoi.  The  first  attack 
of  biliary  colic  occurred  at  Christmas,  1896.  This  had 
been  followed  by  others  at  almost  regular  intervals 
of  three  months  until  January,  1901,  when  the  severest 
attack  of  all  took  place.  She  was  confined  to  bed  after 
it  for  three  months,  and  it  was  after  this  that  she  suffered 
from  continuing  though  varying  jaundice.  Shivering 
was  noticed  on  several  occasions;  on  each  the  pain  was 
rather  worse  and  the  jaundice  a  little  deeper. 

Operation,  June,  1901. — There  were  a  host  of  ad- 
hesions around  the  common  duct,  gall-bladder,  and 
duodenum.     A  stone  was  felt  tightly  fixed  in  the  common 


200        Special  Symptoms  in  Gall-stone  Disease 

duct  near  the  termination  of  the  cystic  duct.  An  in- 
cision was  made  on  to  it  and  a  stone  equal  in  size  to  a 
Barcelona  nut  evacuated.  A  couple  of  drachms  of  pus 
followed  the  stone.  The  common  and  hepatic  ducts 
were  thoroughly  explored  and  found  to  be  clear.  A 
large  drainage-tube  was  fixed  by  one  stitch  into  the  com- 
mon duct  and  the  abdominal  wound  closed  round  the 
tube. 

After  the  operation  there  was  retention  of  urine,  and 
cystitis  followed  upon  catheterism.  Healing  of  the 
wound  was  delayed  by  cellulitis,  due  probably  to  infection 
from  the  pus  escaping  from  the  common  duct.  Bile 
was  discharged  freely  from  the  wound  for  several  weeks. 
A  year  later  the  patient  was  quite  well,  and  her  doctor 
informed  me  that  "  the  relief  from  operation  has  been 
complete." 

Stone  in  the  Comuion  Duct:  Choledochoto)ny. — Miss  B., 
aged  fifty-five.  May,  1902.  Sent  by  Dr.  Clarke,  Don- 
caster.  Two  and  a-half  years  ago  had  the  first  attack 
of  jaundice,  preceded  by  an  extremely  severe  attack  of 
pain  lasting  two  days.  The  jaundice  passed  away  in 
fourteen  days,  and  afterwards  she  felt  quite  well.  In 
December,  1901,  a  similar  attack  of  pain  over  liver, 
passing  through  to  the  right  scapula,  was  followed  by 
jaundice  slight  in  character  and  lasting  only  five  days. 
After  recovery  from  this  attack  she  felt  weak,  easily 
prostrated,  and  had  a  "loathing  for  food."  Flatulence 
was  distressing,  and  her  weight  gradually  decreased. 
Six  weeks  before  admission  a  similar  attack  of  pain, 
followed  by  jaundice ;  since  then  jaundice  has  varied  in 
depth  of  tinge,  but  has  never  disappeared;  pain  has 
varied,  but  a  dull  aching  sense  of  oppression  and  weight 
has  always  been  present.  She  has  had  several  shiver- 
ing attacks  during  the  last  six  weeks.  She  has  lost 
one  and  one-half  stone  in  the  last  three  months.  The 
jaundice  is  said  bv  her  friends  to  be  less  in  the  morn- 


Stone  in  the  Common  Duct  201 

ing,  and  to  get  gradually  deeper  in  tinge  during  the  day. 
On  examination  there  were  tenderness  and  rigidity  in 
the  gall-bladder  area.     Nothing  definite  felt. 

Operation. — A  long  incision  was  made.  The  gall- 
bladder was  found  buried  in  adhesions  thick  and  con- 
tracted. There  were  many  adhesions  between  the  ab- 
dominal wall,  the  liver,  duodenum,  transverse  colon,  and 
bile-ducts — so  firm  and  so  widespread  that  rotation  of  the 
liver  was  not  possible.  A  stone  was  tightly  wedged  in 
the  common  duct  about  one  inch  from  its  junction  with 
the  cystic  duct.  As  the  common  duct  could  not  be 
brought  to  the  surface,  it  was  necessary  to  cut  down  upon 
the  stone  in  the  duct  and  to  remove  it  with  a  scoop. 
The  stone  was  of  the  size  of  a  nutmeg.  The  hepatic 
and  the  rest  of  the  common  duct  were  explored,  but  no 
other  stone  discovered.  A  large  tube  was  fixed  into  the 
opening  made  into  the  duct  and  the  abdominal  wound 
closed. 

The  tube  came  away  on  the  eleventh  day.  The  wound 
rapidly  healed,  and  the  patient  is  now  quite  well  and  free 
from  pain,  discomfort,  and  jaundice. 


THE  DIFFERENTIAL  DIAGNOSIS  OF  STONE   IN   THE 
COMMON   DUCT. 

In  many  cases,  certainly  in  the  majority,  the  diagnosis 
of  stone  in  the  duct  is  correctly  made  with  the  most  posi- 
tive assurance;  in  other  cases  the  surgeon  may  waver  in 
his  diagnosis,  being  uncertain  as  to  whether  a  calculus 
alone  is  present,  or  as  to  whether  a  stone  is  associated 
with  some  other  condition  whose  symptoms  are  similar, 
or,  finally,  as  to  whether  the  symptoms  suggestive  of 
stone  are  being  caused  by  an  entirely  different  condition. 

In  the  characteristic  case  of  common  duct  obstruction 


202        Special  Symptoms  in  Gall-stone  Disease 

by  stone  jaundice  is  always  present  and  is  remarkable 
for  the  great  variation  it  shews  in  depth  of  tinge.  Jaun- 
dice, however,  is  not  an  invariable  sign  in  cases  where 
stones  are  found  in  the  common  duct  during  operation  or 
at  an  autopsy.  Even  when  the  blood  is  examined  by 
Hamel's  method,  no  yellow  discolouration  may  be  found. 
In  the  absence  of  jaundice,  however,  it  is  almost  im- 
possible to  arrive  at  a  correct  diagnosis.  Jaundice  there- 
fore is  the  cardinal  symptom  of  common  duct  obstruction, 
and  is  distinguished  by  a  perfectly  characteristic  "ebb 
and  flow  ' '  in  those  cases  in  which  the  stone  forms  a 
"ball  valve,"  that  is,  in  the  very  great  majority.  The 
"ebb  and  flow"  is,  however,  in  a  certain  number  of  cases 
very  slight,  and  may  escape  notice  by  the  patient,  or 
those  who  are  in  immediate  contact  with  the  patient, 
and  only  obtain  recognition  after  the  medical  man  has 
given  instructions  for  precise  observations  to  be  made. 
(3f  all  the  conditions  Avhich  simulate  calculous  ob- 
struction of  the  common  duct,  probably  none  is  so  difficult 
to  differentiate  as  chronic  pancreatitis.  The  frequency  of 
their  association  is  now  well  recognised,  but  it  is  not  so 
generally  understood  that  even  after  a  stone  has  passed, 
after  long  detention  in  the  duct,  the  thickening  of  the 
head  of  the  pancreas  which  has  been  left  behind  may 
cause  a  remarkable  mimicry  of  the  symptoms  of  stone. 
The  "pancreatic  reaction"  given  by  Cammidge's  test 
may,  if  experience  prove  it  to  be  reliable,  shew  the  ex- 
istence of  pancreatitis,  but  does  not  permit  a  distinction 
between  the  two  diseases.  It  enforces,  however,  the 
imperative  need  of  operation,  in  order  to  prevent  a 
permanent  and   increasing  damage   to  the  pancreas. 


Stone  in  the  Common  Duct  203 

When  the  gall-bladder  is  distended,  we  know,  by 
"  Courvoisiers  law,"  that  in  all  probability  the  jaundice  is 
caused  not  by  stone,  but  by  growth  or  inflammation  press- 
ing upon  the  duct.  In  chronic  pancreatitis  the  gall- 
bladder may  be  dilated,  even  when  the  pancreatic  in- 
flammation is  primarily  caused  by  the  stone  irritation. 
In  the  first  recorded  cases  of  typhoid  pancreatitis  I  had 
diagnosed  stone  in  the  common  duct  from  the  symptoms, 
yet  found  that  the  sole  cause  of  the  intermitting  jaundice 
was  a  condition  of  chronic  inflammation  of  the  pancreas ; 
the  gall-bladder  was  distended  with  bile  containing  an 
abundance  of  the  organisms  of  typhoid  fever.  Cour- 
voisier's  law,  therefore,  though  of  enormous  value  clini- 
cally, is  not  invariably  true.     But  what  law  is? 


CHAPTER  VI. 
REMOTE  CONSEQUENCES  OF  GALL-STONE  DISEASE. 

The  chief  of  these  are  biliary  fistulae  and  their  com- 
plications, perforation  of  the  gall-bladder  into  the  peri- 
toneum, and  intestinal  obstruction. 

Biliary  Fistulae. — Biliary  fistulas  may  form  between  any 
part  of  the  bile-tract,  on  the  one  hand,  and  the  surface  of 
the  skin  or  of  any  of  the  hollow  viscera,  on  the  other. 
They  are  conveniently  classified  as  external  and  internal. 
The  following  table,  compiled  by  Naunyn,  indicates  the 
frequency  with  which  the  \-arious  fistulce  were  found  in  a 
series  of  recorded  cases: 

Between  the  bile-duets  themselves 8 

Retroperitoneal 4. 

Gastric — total   12 

Gastro-hepatie     4 

Between  stomaeh  and  gall-bladder 8 

Dtiodenal — total loS 

Common  duct  and  duodenum 15 

Gall-bladder  and  duodenum 93 

Between  gall-bladder  and  jejunum    i 

Between  gall-bladder  and  ileum     i 

Colic — total 50 

Between  gall-bladder  and  colon 49 

Between  coinmon  duct  and  colon i 

Urinary  passages 6 

Thoracic  viscera   10 

Abdominal  wall     184 

This  table  is  not  supposed,  even  by  its  compiler,  to 

204 


External   Biliary  Fistulse  205 

represent  with  anything  approaching  accuracy  the  true 
state  of  affairs.  For,  as  Naunyn  points  out,  fistulse  of  the 
abdominal  wall  have  always  attracted,  indeed,  compelled, 
observation,  and  other  fistula,  those,  for  example,  impli- 
cating the  urinary  passages,  are  so  remarkable  and  unex- 
pected as  to  seem  worthy  of  especial  record.  The  intes- 
tinal fistulse,  on  the  other  hand,  produce  no  symptoms ; 
indeed,  their  formation  always  affords  relief  to  symptoms 
which  may  often  have  menaced  the  patient's  life.  They 
are  discovered,  moreover,  only  after  tedious  dissection, 
and  are,  therefore,  on  all  grounds,  liable  to  escape  notice. 

External  biliary  fistulas  may  be  due  to  disease  or  may 
follow  operation.  The  fistula  almost  invariably  im- 
plicates the  gall-bladder,  and  is  the  result  of  an  empyema. 
The  suppurative  cholecystitis  may  be  due  to  the  blockage 
of  a  stone  in  the  cystic  duct,  or  be  independent  of  calcu- 
lous disease.  As  a  result  of  the  acute  inflammation  of  the 
gall-bladder,  adhesions  are  formed  to  the  abdominal  wall, 
the  gall-bladder  perforates,  an  abscess  forms,  and  at 
length  the  skin  gives  way.  When  the  abscess  discharges, 
some  or  all  of  the  gall-stones  may  escape  from  the  fistula, 
which  may  then  close  spontaneously.  As  a  rule,  a  single 
fistulous  opening  is  present  and  is  situated  in  the  right 
hypochondrium  or  near  the  umbilicus ;  but  there  may  be 
several  fistulse,  and  these  may  open  anywhere  upon  the 
abdominal  wall.  A  case  of  fistula  discharging  "exactly 
over  the  normal  position  of  the  appendix"  is  recorded 
by  Gibbon  (Phil.  Med.  Journ.,  1901).  Porges  (Wien. 
klin.  Woch.,  1900,  No.  26)  has  described  a  case  in  which 
a   fistula  upon   the   thigh  discharged  gall-stones. 

The  inner  end  of  the  fistula  mav  communicate  with 


2o6    Remote  Consequences  of  Gall-stone  Disease 

the  cystic,  or  common,  or  hepatic  ducts,  or  it  may  follow 
the  opening  of  a  hydatid  cyst  or  hepatic  abscess,  and  will 
then  be  in  relationship  with  the  intra-hepatic  ducts. 
In  addition  to  acute  suppurative  cholecystitis,  injury 
bv  stab  or  gunshot  wound  may  be  mentioned  as  causes. 

Biliary  fistulcC  after  cholecystotomy  were  formerly 
not  infrequent.  Now-a-days  they  are  rarely  seen.  In 
the  earlier  operations  it  was  considered  necessary  to 
stitch  the  gall-bladder  to  the  skin,  and  a  fistula  was, 
therefore,  to  be  expected.  Since  the  gall-bladder  has 
been  fixed,  as  a  rule,  to  the  aponeurosis,  a  fistula  has 
become  an  extreme  rarity. 

The  external  opening  in  Courvoisier's  series  of  169 
cases  was  situated  as  follows: 

In  the  right  hypochondrium    49 

At  the  right  costal  margin 36 

On  the  right  side  of  the  epigastrium 17 

In  the  right  iUac  region 10 

In  epigastrium 6 

Near  the  umbilicus 22 

At  the  umbilicus 12 

Below  the  umbilicus     11 

In  the  left  groin i 

Multiple  openings r 

Internal  Biliary  Fistulae. — These  may  connect  any  one 
part  of  the  bile-tract  with  any  other  part.  Clinically,  as 
will  be  understood,  they  have  little  interest. 

Fistulae  between  the  gall-bladder  and  the  duodenum 
are  common;  those  between  the  cystic  duct  and  the 
duodenum  are  rare ;  those  between  the  common  duct  and 
the  duodenum,  far  more  frequent  than  is  generally  be- 
lieved, owing  to  the  fact  that  many  cases,  in  reality 
fistulous,  have  been  regarded  as  examples  of  unduh'  large 


Internal   Biliary  Fistulae 


20" 


ampullary  openings.  The  hepatic  duct  has  not  been 
known  to  form  a  fistulous  communication  with  any  part 
of  the  intestine. 

The  following  is  the  record  of  a  case  of  cysto-duodenal 
fistula  upon  which  I  operated : 


K.  H.,  female,  aged  fifty-five,  admitted  February 
y,  1 90 1,  complaining  of  pain  in  the  right  epigastric  and 
hypochondriac  regions.  The 
pain  is  intermittent  in  char- 
acter, comes  on  daily  and  un- 
expectedly, lasts  a  few  hours, 
and  then  disappears.  It  is 
three  months  since  the  first 
attack ;  since  then  the  spasms 
have  increased  in  severity  and 
frequency.  When  an  attack 
comes  on  she  feels  cold  and 
faint  and  almost  collapses. 
She  has  never  been  jaundiced. 
A  fortnight  ago  a  tumour  ap- 
peared on  the  right  side  of  the 
abdomen,  described  by  the 
doctor  as  "a  hard,  smooth, 
globular  tumour,  larger  than  a 
golf  ball. ' '  No  tumour  can  be 
felt  now. 

Operation,  on  February  15th.  The  abdomen  was 
opened  through  the  outer  part  of  the  right  rectus  muscle. 
On  exposing  the  gall-bladder  and  adjacent  parts  the 
following  condition  was  found.  The  gall-bladder  was 
distended  with  a  grumous  material;  to  its  outer  surface 
the  omentum  and  the  duodenum  were  adherent ;  the 
omental  adhesions  separated  fairly  easily,  the  duodenal 
wdth  difficulty.     ( )n  detaching  the  duodenum  an  opening 


Fig.  48. — Ulceration  and 
perforation  of  gall-bladder 
into  peritoneal  cavity,  prob- 
ably due  to  calculi  (Guy's 
Hospital  Museum,  No.  1398). 


2o8    Remote  Consequences  of  Gall-stone  Disease 

was  found  between  it  and  the  gall-bladder;  there  was, 
in  fact,  a  fistula  equal  in  diameter  to  a  lead  pencil  between 
the  two  viscera.  In  the  cystic  duct  a  stone  about  the 
size  and  shape  of  a  nutmeg  was  found  tightly  impacted. 
The  gall-bladder,  cystic  duct,  and  stone  were  removed, 
the  cut  end  of  the  duct  being  ligatured  close  to  the  com- 
mon bile-duct  and  the  stump  covered  with  peritoneum. 
The  opening  in  the  duodenum  was  closed  with  sutures  and 
a  split  drainage-tube  with  gauze  wick  passed  down  to  the 
common  duct.  Recovery  was  uninterrupted  and  the 
patient  left  the  hospital  on  ]\Iarch  12th. 

Mr.  Cammidge  examined  the  gall-bladder  and  re- 
ported: "Great  increase  of  fibrous  tissue  and  patches 
of  small-celled  infiltration,  and  patches  of  calcified 
material.  Xo  evidence  of  malignant  disease  in  the  ma- 
terial examined." 


An  interesting  case  of  cysto-duodenal  fistula  is  recorded 
by  Pozzi,  in  which  the  stone  was  found  to  lie  partly  in  the 
gall-bladder  and  partly  in  the  duodenum. 

The  gall-bladder  may  communicate  with  the  stomach, 
and  its  clinical  recognition  may  readily  be  made  by 
observing  the  persistent  vomiting  of  bile.  According  to 
Naunyn,  not  more  than  a  dozen  cases  are  recorded. 
The  following  is  a  good  example: 

Fistula  between  stomach  and  gall-bladder.  Mrs.  T., 
aged  fifty.  Seen  with  Dr.  Galloway,  Otley,  April,  1902. 
Nine  years  ago  had  an  attack  of  typhoid  fever.  Five 
years  ago  began  to  suffer  from  "  spasms"  at  intervals  of  a 
week  to  a  month.  Jaundice  followed  on  every  occasion. 
"Four  months  ago  had  a  very  severe  attack  which  was 
not  followed  by  jaundice ;  the  pain  was  acute  and  in- 
tolerable in  the  right  hypochondriac  region  and  in  tlie 


Internal   Biliary  Fistulse 


209 


Fig.  49. — Shewing  a  large  fistula  leading  from  the  fundus  of  the 
gall-bladder  into  the  duodenum,  through  which  a  large  calculus 
had  passed.  Other  calculi  are  still  contained  in  the  gall-bladder. 
During  the  passage  of  the  gall-stones  along  the  intestine  the  adhesions 
between  duodenum  and  gall-bladder  were  ruptured  during  the  vio- 
lent vomiting  of  the  patient.  Extravasation  into  the  peritoneal  cav- 
ity occurred.  From  a  woman,  aged  twenty-seven.  She  suffered  from 
symptoms  of  acute  peritonitis,  and  died  in  seven  days.  At  the  in- 
spection the  peritoneal  cavity  was  found  to  contain  bloody  serum. 
The  small  intestines  were  extensively  distended  from  the  stomach 
to  within  a  few  inches  of  the  termination  of  the  iletim,  while  the 
caecum  and  colon  were  contracted  and  empty.  At  the  spot  where 
the  distension  ceased  a  large  biliary  calculus  was  found  which  entirely 
filled  the  canal  {vide  Trans.  Path.  Soc,  vol.  1,  p.  255).  (Royal  College 
of  Surgeons'  Museum   No.  282S.) 


14 


2  10    Remote  Consequences  of  Gall-stone  Disease 

epigastrium ;  vomiting  was  severe ;  after  two  days  bile 
was  noticed  in  the  vomit.  From  that  date  she  has 
vomited  almost  every  day,  and  on  all  occasions  bile  has 
been  present  in  the  vomit.  For  the  last  month  she  has 
vomited  daily  between  ten  and  thirty  ounces  of  bile, 
little,  if  at  all,  altered.  She  has  steadily  lost  flesh;  in 
all  about  three  stone  in  weight  have  been  lost  in  four 
and  one-half  months.  The  vomiting  is  not  attended  by 
pain,  but  comes  on  suddenly,  and  about  ten  ounces 
are  ejected  at  one  effort.  The  right  hypochondriac 
region  and  the  epigastrium  w^ere  tender.  No  blood  was 
seen  in  the  vomit  and  the  stomach  was  not  dilated.  The 
diagnosis  rested  betw^een  fistula  communicating  with  the 
gall-bladder,  on  the  one  hand,  and  the  stomach  on  the 
other,  and  infra-ampullary  growth  in  the  duodenum. 
The  history  pointed  strongly  to  the  former,  and  it  was 
that  which  I  accepted. 

As  I  was  at  the  time  suffering  from  a  poisoned  w^ound 
of  the  hand  I  was  unable  to  operate  myself.  My  col- 
league, Mr.  W.  H.  Brown,  in  whose  beds  she  was,  kindly 
undertook  the  operation  for  me.  He  found  a  fistula 
between  the  fundus  of  the  gall-bladder  and  the  anterior 
wall  of  the  stomach  near  the  pylorus.  The  gall-bladder 
and  stomach  were  detached,  the  opening  in  the  stomach 
closed,  and  the  gall-bladder  drained.  The  stitches  used 
to  close  the  stomach  opening  were  applied  with  difficulty, 
as  they  cut  through  the  friable  stomach  wall  very  readily. 

The  patient  died  forty-eight  hours  after  operation, 
and  it  was  found  that  two  of  the  stomach  sutures  had 
given  way. 

In  some  instances  gall-stones  have  been  vomited,  as  is 
recorded  by  Oppolzer,  Miles,  Frerichs,  Murphy,  myself, 
and  others.  Hayem  has  recorded  a  case  where  gall- 
stones were  evacuated  through  a  stomach- tube.     Van  der 


Internal   Biliary  Fistulae 


21  I 


Byl  has  related  the  history  of  a  case  in  which  gall-stones 
were    vomited;    at    the    postmortem    a    cysto-duodenal 


Fig  50. — Gall-stones  biliary  obstruction;  cholecysto-colic  fistula. 
The  gall-bladder  is  adherent  to  the  liver,  thickened  and  contracted, 
and  contains  a  gall-stone.  The  colon  is  adherent  to  the  fundus,  com- 
municating with  it  by  several  ulcerated  openings.  The  common 
bile-duct  admits  the  middle  finger,  a  calculus  being  lodged  at  its 
end.  One  and  a  half  inches  above  the  papilla  is  seen  an  open- 
ing in  the  wall  of  the  duodenum  leading  into  the  dilated  duct  above 
the  stone.  From  a  man,  aged  sixty,  who  was  admitted  for  slight 
jaundice  of  sixteen  months'  duration  and  enlargement  of  the  liver. 
Death  took  place  sixteen  weeks  later ;  the  body  was  deeply  jaun- 
diced. There  was  tuberculous  disease  of  the  meninges,  lungs,  pericar- 
dium, peritoneum,  and  spleen  (Guy's  Hospital  Museum,  No.  1423). 

fistula  was  found.     The  duodenum  is  more  commonly 
involved  than  either  the  colon  or  the  stomach,  as  might 


212    Remote  Consequences  of  Gall-stone  Disease 

be  anticipated  from  the  anatomical  relations  of  the  parts. 
The  jejunum  and  ileum  are  rarely  affected. 

The  preparatory  stages  in  the  formation  of  fistulae 
connecting  the  gall-bladder  with  the  stomach,  duodenum, 
or  colon  can  not  seldom  be  seen  during  the  performance 
of  operations.  The  gall-bladder  may  be  found  intensely 
adherent,  and,  in  separating  it,  its  walls  may  be  torn  or  the 
intestine  or  stomach  may  be  opened.  Or,  on  completely 
effecting  the  separation,  it  can  be  seen  that  the  walls 
on  one  or  other  side  are  thinned  and  that  the  peritoneal 
coat  is  wholl}"  lost.  In  such  conditions  a  fistula  would 
soon  have  developed.  A  further  step  is  seen  in  those 
cases  in  which  the  gall-stone  has  ulcerated  completely 
through  the  walls  of  the  gall-bladder,  but  has  not  reached 
the  general  peritoneal  cavity,  owing  to  the  protective 
barriers  formed  by  the  copious  outpouring  of  lymph. 
Such  cases  are  recorded  b}^  Sharman  (Med.  Times  and 
Gazette,  1859),  and  Mr.  Simon  (Trans.  Path.  Soc,  vol.  5, 
p.  156)  quoted  two  cases  from  St.  Thomas's  Hospital, 
where  a  process  of  discharge  of  stones  from  the  gall- 
bladder had  appeared  to  be  in  progress  at  the  time  of 
death.  In  one  (whereof  the  specimen  is  preserved  in  the 
museum)  there  was  found  beyond  the  fundus  of  the 
gall-bladder  a  cyst,  constructed  of  dense  cellular  tissue, 
communicating  with  the  gall-bladder  by  a  small  ulcerated 
opening  and  completely  filled  in  its  interior  by  a  con- 
cretion of  cholesterin.  In  another  of  such  transitional 
cases  (Postmortem  Book,  October  19,  1850)  the  fundus  of 
the  gall-bladder  was  found  communicating  by  an  ulcer- 
ated opening  a  quarter  of  an  inch  in  diameter,  with  a 
cyst  about  as  large  as  a  pigeon's  egg,  formed  of  dense. 


Internal   Biliary  Fistulse  213 

cellular  tissue,  coherent  with  the  abdominal  wall  an- 
teriorly and  filled  with  irregular  masses  of  concrete 
biliary  matter  and  small  calculi. 


Fig.  51. — Gall-stone  removed  from  the  ileum  by  operation.  The 
stone  is  two  inches  long,  more  than  one  inch  in  diameter,  weighs 
238  grains,  and  is  moulded  to  the  shape  of  the  gall-bladder.  The 
gall-bladder  is  thickened  and  contracted,  and  there  is  a  fistulous 
communication  between  it  and  the  bowel,  the  parts  being  united 
by  firm  adhesions.  The  anterior  edge  of  the  liver  is  thin  and  bent 
back  upon  the  upper  surface  of  the  organ.  Froin  a  woman,  aged 
fifty,  who  was  admitted  with  symptoms  of  acute  intestinal  obstruc- 
tion of  three  days'  duration,  never  having  previously  suffered  from 
any  illness  except  occasional  dyspepsia.  At  the  laparotomy  the 
peritoneum  was  found  to  be  acutely  inflamed.  After  death  which 
took  place  seventy  hours  later,  the  incision  in  the  piece  of  gut 
separately  shewn  was  found  to  be  12  inches  above  the  caecum  (Guy's 
Hospital  Mtiseum,  No.  1455). 

In  cases  where  gall-stones  of  large  size  are  found  in  the 
faeces,  or  when  intestinal  obstruction  results  from  the 
plugging  of  the  lumen  of  the  gut,  it  is  certain  that  in 
almost  every  instance  the  stone  has  passed,  not  through  the 


2  14    Remote  Consequences  of  Gall-stone  Disease 

common  duct,  but  through  a  fistula.  The  largest  stones 
that  have  been  known  to  pass  are  referred  to  subse- 
quently.    After  the  stone  or  stones  have  escaped  from 


Fig.  52. — Cholecysto-duodcnal  listula;  gall-stone  impacted  in  the 
ileum.  The  gall-bladder  is  thickened  and  contracted  and  firmly- 
adherent  to  the  duodenum.  The  fistula  easily  admits  the  middle 
finger.  The  opening  into  the  intestine  is  situated  about  one  inch 
from  the  pyloric  ring.  The  stone  measures  one  and  one-half  by  one  inch . 
From  a  woman  of  fifty-nine,  who  was  admitted  for  intestinal  obstruc- 
tion. For  six  days  she  had  suft'ered  from  constipation,  vomiting, 
and  abdominal  pain.  Two  days  later  an  artificial  anus  was  estab- 
lished in  the  small  intestine.  Death  ensued  in  six  hours.  The 
stone  was  impacted  33  inches  above  the  ileo-caecal  valve  (Guy's  Hos- 
pital Museum    No.   1399). 


the  bile  passages  into  the  intestine,  the  fistulous  track 
may  close.  Roth  observed  one  such  instance.  Fistulce 
from  the  gall-bladder  generally  open  near  the  fundus, 


Internal   Biliary  Fistiilae  215 

but  any  part  down  to  and  including  the  cystic  duct  may 
be  involved. 

The  occurrence  of  choledocho-duodenal  fistulae  is  prob- 
ably far  more  common  than  is  generally  recognised. 
When  the  first  or  second  portions  of  the  duct  are  impli- 
cated, a  recognition  of  the  fistula  is  easy;  but  when  the 
transduodenal  portion  is  involved,  the  appearances 
presented  are  most  deceptive.  If  a  stone  be  blocked  in  the 
ampulla,  it  may  break  loose  by  causing  ulceration  of  the 
papilla,  or  of  the  lower  part  of  the  duct,  as  it  lies  within 
the  duodenal  wall.  The  lower  end  of  the  duct  then  ap- 
pears to  open  by  a  long  slit  in  the  duodenum  rather  than 
by  a  minute  orifice  on  a  pout  of  mucous  membrane. 
Many  records  speak  of  a  "wide-mouthed  termination," 
or  "an  abnormally  large  opening"  of  the  common  duct. 
In  reality  a  choledocho-duodenal  fistula  is  present. 

There  are  no  symptoms  which  are  especially  due  to 
any  of  these  varieties  of  fistula.  In  many  cases  their 
formation  might  be  expected  to  afford  relief  to  long- 
troublesome  symptoms,  but  their  discovery,  in  most 
cases,  is  a  matter  of  chance.  If,  for  example,  an  im- 
permeable block  were  present  in  the  common  duct,  the 
formation  of  a  cysto-duodenal  fistula,  or  of  a  choledocho- 
duodenal  fistula,  the  former,  imitated  by  the  surgeon  in 
the  operation  of  cholecystenterostomy,  would  give  relief 
to  all  the  symptoms. 

The  following  are  the  notes  of  a  case  in  which  a  fistula 
was  diagnosed,  with  every  probability  of  accuracy: 

Dr.  M.  S.,  aged  fifty-eight,  had  suffered  for  several 
years  from  "indigestion,"  epigastric  colic,  and  occasional 


2i6    Remote  Consequences  of  Gall-stone  Disease 

vomiting.  Seven  months  before  I  saw  him  he  became 
jaundiced  for  the  first  time,  after  an  attack  in  which  the 
foregoing  symptoms  were  unusually  severe.  The  jaun- 
dice persisted,  but  shewed  the  ebb  and  flow  characteristic 
of  ball-valve  stone  in  the  common  duct.  There  were  the 
usual  symptoms  of  ball- valve  stone,  rigors,  sweating, 
pains  in  and  around  the  hepatic  area,  slight,  transient 
enlargement  and  tenderness  of  the  liver,  during  the  whole 
of  the  seven  months.  I  advised  operation,  in  order  that 
the  stone  in  the  common  duct  should  be  removed.  While 
debating  the  matter  an  attack  of  colic  of  the  usual  type 
began.  Three  days  later  a  stone,  as  large  as  a  nutmeg, 
was  passed;  the  jaundice,  after  deepening,  gradually 
cleared  away,  and  for  the  last  four  and  one-half  years 
there  have  been  no  symptoms  of  an}"  kind.  After  the 
discovery  of  the  large  stone  no  further  search  w^as  made, 
and  it  is,  therefore,  impossible  to  say  whether  others  were 
passed. 

When  intestinal  obstruction  follows  speedily  upon  an 
attack  of  pain,  swelling,  and  tenderness  in  the  hepatic 
region,  and  a  gall-stone  is  recognised  as  being  the  cause 
of  the  block,  it  will  be  clear  that,  in  all  probability,  a 
fistula  has  formed.  Such  cases  are  not  unusual.  Fistulae 
between  the  gall-bladder  and  the  colon  are  not  infre- 
quent. They  may  be  diagnosed  when  a  large  stone  is 
passed  per  anum  without  any  biliary  or  intestinal  dis- 
comfort having  been  observed.  As  a  rule,  the  beginning 
of  the  transverse  colon  is  joined  to  the  gall-bladder.  As 
Courvoisier  was  the  first  to  point  out,  a  cysto-colic 
fistula  is  not  seldom  associated  with  other  fistulas,  cysto- 
duodenal,  choledocho-duodenal,  and  so  forth.  One 
example  of  fistula  between  the  common  duct  and  the 


Internal  Biliary  Fistulse  217 

colon  is  recorded.  Riedel  relates  a  case  of  cysto-colic 
fistula  in  which  death  occurred  four  hours  after  the  per- 
foration of  the  gall-bladder  near  its  point  of  junction 
with  the  colon.  Faeces  and  gall-stones  were  found  free 
in  the  peritoneal  cavity. 

Among  the  surgical  curiosities  are  fistulae  which  have 
formed  betiveen  the  bile  passages  and  the  urinary  tract.  I 
have  once  seen  a  gall-stone,  which  had  escaped  from  the 
gall-bladder  into  a  renal  pelvis,  dilated  behind  an  im- 
pacted ureteral  calculus.  A  stone  so  placed  may  escape 
into  the  bladder.  Guterbock  has  performed  lithotrity 
and  Bier  lithotomy  for  what  were  found  to  be  gall-stones. 
Murchison  records  a  case  where  200  gall-stones  were 
passed  from  the  bladder.  In  such  rare  cases  the  tract 
between  the  gall-bladder  and  the  urinary  passages  may 
be  very  long  and  tortuous. 

It  has,  indeed,  been  shewn  that  a  path  may  be  created 
along  the  round  ligament  of  the  liver  to  the  umbilicus, 
and  thence  along  a  patent  urachus  to  the  bladder. 

Pelletan  records  a  case  of  gall-stone  impacted  in  the 
urethra  which  was  pushed  onwards  by  the  pressure  of  a 
finger  in  the  vagina.  This  stone  was  the  last  of  200  little 
stones  that  were  passed  within  a  period  of  eight  days. 

Faber  records  the  case  of  a  man  who  sufi:ered  for  four 
years  from  gall-stone  disease ;  calculi  passed  by  the  bowel, 
and  nine  small  and  four  large  stones  were  voided  with  the 
urine.  One  of  these  became  impacted  in  the  urethra 
and  the  patient  himself  extracted  it.  A  second  stone 
became  impacted,  and  this  could  only  be  removed  after 
the  performance  of  external  urethrotomy.  The  stones 
were   passed   between   the   years    1834   and    1838.     The 


2i8    Remote  Consequences  of  Gall-stone  Disease 

patient  died  in  1863,  and  a  postmortem  examination 
shewed  the  existence  of  a  connecting  strand  between  the 
gall-bladder  and  the  urinary  bladder.  The  upper  half 
of  this  strand  consisted  of  the  gall-bladder,  the  lower 
half  of  a  patent  urachus. 

Abt  records  the  case  of  a  woman  thirty  years  of  age 
who  suffered  for  eleven  months  from  gall-stone  attacks. 
Eleven  calcuH  were  passed  in  the  urine  and  recovery 
speedily  followed. 

J.  Israel  communicated  a  case  to  Langenbuch,  which 
the  latter  records,  in  which  a  gall-stone  was  found  in  the 
urinary  bladder. 

Cases  are  recorded  in  which  operative  treatment  has 
been  adopted  by  Kocher,  von  Bergmann,  and  Kronlein. 
In  Kronlein' s  case  a  communication  existed  between  the 
gall-bladder  and  the  urinary  bladder  through  a  patent 
urachus.  The  gall-bladder  was  removed  and  the  urachus 
closed.  The  patient,  a  woman  aged  fifty-six,  died  three 
days  later  as  a  result  of  the  giving  way  of  the  ligature 
upon  the  cystic  duct. 

Von  Bergmann 's  patient  was  a  woman  sixty-three  years 
of  age  who  had  suffered  for  eighteen  years  from  pain  and 
inflammatory  swelling  in  the  right  hypochondrium, 
A  tumour  the  size  of  a  fist  formed  in  the  neighbourhood 
of  the  umbilicus.  This  was  opened  and  gall-stones  were 
removed  from  what  was  recognised  as  being  a  dilated 
urachus.     The  patient  recovered. 

Fistulae  Between  the  Bile  Passages  and  the  Female 
Genital  Organs. — In  one  very  remarkable  example  re- 
lated by  J.  P.  Frank,  in  1790,  a  gall-stone  is  supposed 
"to  have  passed  along  a  fistula  between  the  gall-bladder 


Fistulse  Between  Bile  Passages  and  Genitals     219 

and  the  uterus,  and  to  have  escaped  from  the  vagina 
during  labour."  The  case,  however,  is  open  to  question. 
The  patient,  at  the  age  of  twenty- two,  had  suffered,  w^hen 
pregnant,  from  severe  pain  to  the  right  of  the  uterus. 
After  confinement  there  was  profuse  hsemorrhage.  Three 
months  later  a  hard,  round  lump  was  felt  to  the  right  of 
the  uterus.  It  remained  stationary  in  size,  but  was  very 
painful  during  menstruation.  Pregnancy  occurred  after 
eight  years,  and  at  once  the  swelling  increased  in  size  and 
became  continuously  painful.  After  a  few  weeks  pus 
escaped  from  the  vagina.  An  incision  was  made  into  the 
swelling  and  pus  was  evacuated.  From  this  opening 
pus  continued  to  escape  and  the  discharge  from  the 
vagina  gradually  lessened.  After  some  weeks  a  sudden 
pain  was  experienced,  followed  by  shivering,  jaundice,  and 
convulsions.  Bile  was  discharged  from  the  fistula  and  from 
the  intestine.  A  gall-stone  escaped  into  the  vagina,  and 
later  twenty-five  were  passed  in  the  faeces.  Delivery  was 
induced  at  the  seventh  month.  The  closure  of  the  fistula 
speedily  followed.  There  is  here  no  mention  of  the 
escape  of  the  stone  during  labour.  The  case  is  one  either 
of  vaginal  or  uterine  fistula.  More  than  that  cannot  be 
said. 

Two  cases  are  recorded  by  Osier  and  Kummell  in  which 
a  stone-containing  gall-bladder  became  adherent  to  the 
broad  ligament  and  the  ovary.  A  case  of  biliary  fistula 
between  the  gall-bladder  and  the  pregnant  uterus  is 
mentioned  by  Faber.  R.  H.  Lucy  (Lancet,  April  21, 
1900,  p.  1 132)  records  a  case  of  ovarian  cyst  communicat- 
ing with  a  thickened  gall-bladder  containing  a  solitary 
calculus.  The  contents  of  the  ovarian  cyst  were  bile- 
stained. 


2  20    Remote  Consequences  of  Gall-stone  Disease 

Fistulse  may  connect  the  bile  passages  and  the  thoracic 
organs.  A  subphrenic  abscess,  or  an  intense  inflammatorv 
deposit,  may  form  as  the  result  of  an  empyema  of  the 
gall-bladder  or  an  abscess  of  the  liver.  The  pleura  may 
become  adherent  on  the  upper  surface  of  the  diaj)hragm, 
and  when  the  wall  of  the  gall-bladder  or  of  the  abscess 
gives  way,  the  gall-stones  may  escape  into  the  lung,  and 
there  cause  an  abscess  to  form.  Gall-stones,  bile,  and  pus 
may  be  coughed  up,  and  the  taste  of  bile  may  be  recog- 
nised by  the  patient.  Cayley  has  recorded  a  case  where 
gall-stones  entered  the  left  pleura  from  the  left  lobe  of 
the  liver ;  Simons  one  where  the  mediastinum  was  opened ; 
and  Wickham  Legg  one  in  which  the  pericardium  was 
involved.  A^issering  and  Colvee  have  recorded  cases  in 
which  gall-stones  were  expectorated .  Harley  found  stones 
in  a  pleural  effusion.  So  far,  almost  all  such  cases  have 
proved  fatal. 

Courvoisier,  in  his  work,  collected  twenty-four  cases  of 
fistulcc  between  the  bile  passages  and  the  pleura  of  the 
lungs.  Graham  (Brit.  Med.  Journ.,  vol.  i,  1897,  p.  1397) 
published  ten  additional  cases,  including  two  observed  by 
himself.  In  Courvoisier's  series  of  cases  a  necropsy  was 
performed  in  eighteen  cases ;  in  ten  of  these  the  fistula  was 
found  to  be  secondary  to  gall-stones.  The  usual  sequence 
of  events  in  these  cases  is  ( i )  occlusion  of  the  common  bile- 
duct;  (2)  suppurative  cholangitis,  extending  upwards  to 
the  liver  and  causing  biliary  abscess;  (3)  adhesions  of  the 
liver  to  the  under  surface  of  the  diaphragm ;  (4)  adhesions 
of  the  lung  to  the  upper  surface  of  the  diaphragm;  (5) 
perforation  of  the  li\'er,  diaphragm,  and  lung  and  escape 
of  bile  into  the  bronchi. 


Fistulse  Between  Bile  Passages  and  Genitals    221 

In  a  very  few  cases  surgical  treatment  has  been  at- 
tempted. The  following  case  is  recorded  by  Mr.  Rigby 
(Brit.  Med.  Journ.,  vol.  2,  1903,  p.  313): 

History. — A  female  patient,  aged  fifty,  was  admitted 
into  the  Poplar  Hospital  on  December  14,  1902,  with  the 
following  history: 

She  had  been  an  in-patient  in  the  Radcliffe  Infirmary, 
Oxford,  eighteen  months  ago,  owing  to  a  severe  illness 
which  lasted  for  six  weeks.  The  symptoms,  w^hich  were 
acute  for  the  first  week  after  admission,  were  those 
of  cholangitis,  due  probably  to  gall-stones,  jaundice, 
pyrexia,  and  pain  in  the  right  hypochondriac  region  be- 
ing present.  The  acute  symptoms  gradually  subsided 
and  no  operative  treatment  was  carried  out. 

About  ten  days  before  admission  she  had  a  severe  fit 
of  coughing,  which  resulted  in  the  expectoration  of  some 
green  fluid  with  a  very  bitter  taste;  since  that  time  she 
had  been  troubled  with  a  persistently  distressing  cough 
and  expectoration  of  similar  fluid.  She  had  kept  in  bed 
and  lived  on  milk  diet  for  the  last  ten  days.  She  thought 
she  had  wasted  a  good  deal. 

Condition  on  Admission. — A  fairly  well-nourished  wo- 
man, looking  somewhat  prematurely  aged.  The  colour  of 
the  face  appears  normal,  but  the  conjunctiva  are  a  little 
yellow.  The  tongue  is  red  and  clean.  She  is  not  in  pain, 
but  complains  greatly  of  cough,  which  is  frequent  and 
distressing.  After  each  fit  of  coughing  she  brings  up  with 
but  little  effort  a  drachm  or  two  of  dark-green  frothy 
fluid  expectoration,  which  she  says  has  a  bitter,  unpleasant 
taste.  She  cannot  lie  down  at  all,  owing  to  this  per- 
sistent desire  to  cough.     There  is  no  pyrexia. 

The  lungs  on  examination  show  well-marked  signs  of 
emphysema,  as  evidenced  by  hyper-resonance,  with  pro- 
longed expiration ;  rhonchi  and  rales  are  audible  on  both 


222    Remote  Consequences  of  Gall-stone  Disease 

sides;  the  heart  sounds  are  clear,  and  the  apex  beat  is 
heard  in  the  normal  position. 

The  abdomen  is  flaccid,  but  examination  in  the  re- 
cumbent posture  is  difficult,  owing  to  the  incessant 
desire  to  cough.  The  liver  can  be  felt  below  the  costal 
margin  for  about  two  fingerbreadths,  and  on  percussion 
dulness  corresponds  with  this.  There  is  no  increase  of 
liver  dulness  in  an  upward  direction.  Some  tenderness  is 
evinced  on  palpation  over  its  anterior  margin  and  in 
the  gall-bladder  region,  but  this  is  slight,  and  nothing 
resembling  an  enlarged  gall-bladder  can  be  felt.  No  rub 
can  be  felt  over  the  liver  region.  The  rest  of  the  abdomen, 
both  to  percussion  and  palpation,  appears  normal. 

The  sputum  was  carefully  examined  and  gave  the 
characteristic  reactions  for  bile,  which  appeared  to  be 
present  in  considerable  quantities. 

Operation. — On  February  17th  the  patient  was  an- 
aesthetised with  A.  C.  E.  mixture,  and  the  following 
operation  performed  by  Mr.  Hugh  Rigby.  A  sandbag 
was  first  placed  transversely  beneath  the  lower  dorsal 
region.  An  incision  was  then  made  in  the  upper  part 
of  the  right  linea  semilunaris,  three  and  one -half  inches 
in  length.  The  liver  came  into  view  on  opening  the 
peritoneum.  It  was  enlarged  downwards,  its  edge  ex- 
tended one  and  one-half  inches  below  the  costal  margin, 
it  appeared  congested,  and  its  anterior  border  was 
rounded. 

The  fundus  of  the  gall-bladder  was  seen,  but  the  body 
of  this  viscus  was  concealed  from  view  by  the  hepatic 
flexure  of  the  colon,  which  was  adherent  to  it  and  to  the 
inferior  surface  of  the  liver.  The  adhesions  were  care- 
fully separated ;  the  colon  was  found  to  be  firmly  fixed  at 
one  point  to  the  liver,  to  the  right  of  the  gall-bladder.  In 
separating  this  the  wall  of  the  gut  was  slightly  torn ;  the 
opening  was  immediately  closed  by  two  Lembert  sutures 
of  silk.     The  gall-bladder,  cystic  and  common  bile-ducts 


Perforation  into  Portal  Vein  223 

were  then  exposed.  The  gall-bladder  was  found  to  be 
empty,  contracted,  and  its  walls  thickened  and  fibrous. 
The  cystic  duct  was  slightly  dilated.  The  common  duct 
was  distended  to  about  the  size  of  one's  forefinger. 
Some  calculi  were  felt  low  down  in  the  common  duct 
behind  the  head  of  the  pancreas. 

An  incision  one  inch  in  length  was  made  in  the  common 
bile-duct,  above  the  first  part  of  the  duodenum.  A  good 
deal  of  dark  bile  escaped,  which  was  quickly  sponged 
away.  By  means  of  a  finger  and  thumb  the  calculi  were 
squeezed  up  from  behind  the  pancreas  and  first  part  of 
the  duodenum,  and  made  to  present  in  the  wound  in  the 
duct,  and  were  then  extracted  without  difficulty.  There 
were  two  calculi  present.  After  their  extraction  a  probe 
could  be  easily  passed  down  into  the  duodenum.  The 
opening  in  the  common  bile-duct  was  then  closed  by  two 
rows  of  sutures,  one  for  cut  edges  of  the  wound  and 
another  for  serous  covering  by  Czerny-Lembert  method. 
The  gall-bladder  was  next  sutured  by  silk  to  the  peri- 
toneum of  the  wound  in  the  belly  wall  at  its  upper  part, 
and  the  rest  of  the  wound  closed  by  silkworm-gut 
sutures. 

The  fundus  of  the  gall-bladder  was  incised  and  a  small 
drainage-tube  inserted,  but  no  bile  escaped  at  all  from 
the  gall-bladder.  A  gauze  drain  was  passed  down  to 
the  opening  in  the  common  duct  through  the  lower  part 
of  the  abdominal  wound.  The  calculi  were  facetted, 
dark  green  in  colour,  and  evidently  composed  of  bile 
pigment  and  cholesterin.  The  larger  was  the  size  of  a 
marble,  the  smaller,  that  of  a  hazelnut.  The  patient 
made  a  good  recovery. 

Perforation  of  a  stone  from  the  common  bile-duct  into 
the  portal  vein  has  been  observed  on  four  occasions ;  in 
one,  a  stone  lay  partly  in  the  pelvis  of  the  gall-bladder 


224    Remote  Consequences  of  Gall-stone  Disease 

and  partly  in  the  vein;  in  one,  a  stone  half  an  inch  in 
length  had  ulcerated  into  the  vein  adherent  to  the  head 
of  a  malignant  pancreas;  in  one,  there  was  a  subhepatic 
abscess;  in  one,  a  stone  2  cm.  in  length,  composed  of 
cholesterin,  lay  in  the  portal  vein,  and  other  smaller 
stones  were  found  in  the  branches.  Thrombosis  of  the 
portal  vein  due  to  compression  by  a  stone  in  the  hepatic 
or  common  ducts  is  also  recorded.  Ascites  may  be 
caused  by  thrombosis,  and  also  by  direct  pressure  upon 
the  portal  vein  by  the  stone.  In  several  instances  stones 
have  been  found  to  have  ulcerated  out  of  the  bile  passages 
and  to  lie  in  cavities  of  the  liver  substance,  or  to  be 
confined  within  an  abscess  cavity  hemmed  in  by  peri- 
toneal adhesions.  I  have  met  with  several  examples 
of  the  former  and  with  one  of  the  latter  condition,  in 
operations  for  gall-stones. 

in  rare  instances  multiple  internal  fistulae  may  be 
present.  Ignatius  Loyola  is  said,  upon  the  authority  of 
Realdo  Colombo,  to  have  suffered  from  gall-stone  dis- 
ease, and  gall-stones  were  found  in  the  liver,  portal  vein, 
kidneys,  and  lungs.  Morgagni  remarks  that  the  intra- 
hepatic ducts  were  probably  mistaken  for  the  portal  vein. 

Internal  and  external  fistulae  may  both  be  present, 
as  in  the  following  very  remarkable  example  recorded  bv 
Leonard  Rogers  (Brit.  Med.  Journ.,  vol.  2,  1903,  p.  706) : 

The  patient,  a  man,  was  first  admitted  to  St.  Mary's 
Hospital  for  empyema  of  the  gall-bladder,  which  was 
successfully  drained,  the  pus  being  bile-stained.  The 
wound  healed  and  the  patient  left  the  hospital  only  to 
return  shortly  after,  coughing  up  bile-stained  pus.  This 
continued  in  varying  degree  for  upwards  of  a  year,  the 


Fistulse  into  Duodenum  225 

case  being  considered  to  be  one  of  suppurating  hydatid 
cyst  of  the  Hver  opening  through  the  lung.  Lastly,  a 
perinephric  abscess  formed  and  was  opened,  the  pus  being 
again  bile-stained,  and  the  patient  died  exhausted  a 
few  weeks  later.  Postmortem,  the  liver  was  found 
riddled  by  suppuration.  The  bile-ducts  were  found  very 
greatly  dilated  above  some  gall-stones  and  full  of  pus. 
On  tracing  up  the  dilated  ducts  a  long  probe  could  be 
passed  from  the  common  hepatic  duct  through  the  liver 
and  diaphragm  into  an  abscess  in  the  base  of  the  right 
lung  and  into  the  right  bronchus.  A  direct  communica- 
tion could  also  be  traced  between  the  dilated  hepatic 
duct  and  the  perirenal  abscess,  while  the  scar  of  the 
empyema  wound  also  led  through  the  diaphragm  down 
to  another  dilated  pus-containing  hepatic  duct. 

A  case  in  which  fistulas  from  the  gall-bladder  led  into 
the  duodenum,  the  stomach,  and  the  colon  is  recorded  by 
Naunyn  (p.   152). 

There  is  a  specimen  in  the  Museum  at  Saint  Barthol- 
omew's Hospital  which  shews  two  fistulae  leading  from 
the  gall-bladder,  one  into  the  ileum  the  other  into  the 
colon. 

Fistulas  between  one  part  of  the  bile  passages  and 
another  have  been  observed  in  eight  cases.  They  are 
found  between  the  gall-bladder  and  the  hepatic  duct 
(Ottiker  and  Fauconneau-Dufresne)  or  between  the  gall- 
bladder and  the  common  duct  (Schloth).  Only  a  path- 
ological interest  attaches  to  these  conditions. 


15 


CHAPTER  VII. 
PERFORATION  OF  THE    GALL-BLADDER. 

Gall-stones,  in  working  their  way  through  the  walls 
of  the  gall-bladder,  may  give  rise  to  various  conditions. 
They  may  ulcerate  through  that  wall  of  the  gall-bladder 
that  lies  in  contact  with  the  liver  and  so  come  at  last 
to  lie  in  cavities  in  the  liver  substance  entirely  outside 
the  gall-bladder,  but  communicating  with  it  by  the  open- 
ing through  which  the  stones  have  escaped.  This  is 
by  no  means  an  infrequent  occurrence — one  which  may 
pass  unnoticed  when  cholecystotomy  is  performed.  If, 
however,  cholecystectomy  be  attempted,  it  will  then 
be  found  that  what  seemed  on  first  examination  to  be 
nothing  more  than  a  greatly  thickened  gall-bladder  is 
in  reality  a  mass  of  inflammatory  thickening  around  a 
fistulous  track  leading  into  the  liver,  in  which  one  or 
many  gall-stones  may  be  found.  In  my  first  20  cases  of 
cholecystectomy  I  found  no  fewer  than  four  in  which 
stones  had  found  their  way  through  the  gall-bladder 
wall  into  the  substance  of  the  liver. 

Stones  ulcerating  through  the  surface  of  the  gall- 
bladder clad  with  peritoneum  may  have  their  passage 
barred  at  the  first  by  a  mass  of  protective  adhesions, 
which  have  been  thrown  out  around  the  gall-bladder. 
In  such  circumstances  a  stone  may  have  escaped  entirely 
from  the  gall-bladder  and  be  found  in  the  centre  of  a 

226 


Perforation  of   the  Gall-bladder 


227 


mass  of  organised  lymph  or  of  omental  adhesions.  If 
there  should  be  an  infection  of  this  cavity,  a  localised 
abscess  will  form,  but  suppuration  does  not  necessarily 
follow  upon  the  perforation  of  the  gall-bladder,  for  stones 
which  lie  in  adherent  masses  of  omentum  may  have 
caused   therein   no   obvious   signs   of   inflammation.     In 


Fig.  53. — Gall-bladder  shewing  stones  in  process  of  ulceration 
through  the  gall-bladder;  one  stone  is  seen  to  be  almost  through 
(from  a  successful  case  of  cholecystotomy) . 


many  recorded  cases  a  "secondary  gall-bladder"  has 
been  formed  around  gall-stones  which  have  ulcerated 
through  the  walls  of  the  gall-bladder  into  a  mass  of 
adhesions.  Within  this  space  stones  may  lie  at  rest 
for  several  years.  Acute  symptoms  are,  however, 
aroused  either  by  the  onset  of  a  virulent  infection  or 
by  the  rupture  of  the  secondary  gall-bladder,  or  by  the 


228  Perforation  of   the  Gall-bladder 

detachment  of  any  omental  adhesion  which  has  formed 
a  part  of  its  walls.  The  following  case  is  recorded  by- 
Morton  (Lancet,  1893,  vol.   i,  p.  586): 

The  patient  was  a  female,  aged  sixty,  who  gave  the 
following  history:  Two  years  before  death  the  patient 
suffered  from  slight  jaundice  of  about  nine  days'  duration, 
without  any  colic.  During  the  last  year  she  had  several 
attacks  of  severe  abdominal  pain,  chiefly  on  the  right 
side,  with  vomiting.  She  had  never  been  jaundiced 
during  the  last  two  years.  Neither  had  there  been  any 
ague-like  paroxysms. 

Postmortem. — The  abdomen  was  distended,  and  on 
opening  it  much  orange-coloured  fluid  escaped  and 
general  recent  adhesive  peritonitis  was  discovered.  Just 
below  the  liver  was  a  cavity  the  size  of  an  orange,  bounded 
above  by  the  under  surface  of  the  liver  and  in  front  by 
the  thin  margin  of  the  liver  and  the  omentum  which 
had  been  adherent  to  it.  Below,  it  was  separated  from 
the  colon  by  much  thickened  tissue.  On  its  inner  side 
lay  the  omentum,  and  on  its  outer  side,  covered  by  ad- 
hesions between  the  liver  and  adjacent  parts,  lay  the 
gall-bladder,  which  opened  into  the  cavity  by  an  aper- 
ture .which  would  admit  one  or  two  fingers.  The  wall 
of  the  gall-bladder  was  much  thickened,  and  several 
stones  half  an  inch  in  diameter  were  found  lying  in  it. 
Where  the  omentum  had  before  been  adherent  to  the 
anterior  edge  of  the  liver,  forming  the  anterior  wall 
of  the  cavity,  it  had  become  detached,  and  thus  the  bile 
had  escaped  into  the  peritoneum  and  set  up  fatal  peri- 
tonitis. 

In  the  common  duct,  just  where  the  cystic  and  hepatic 
ducts  join,  was  another  gall-stone,  square  or  nearly  so, 
and  half  an  inch  across  in  all  directions.  The  wall  of 
the  duct  around  it  was  much  thickened,  but  it  did  not 


I 


>«j^ 


'  Jy  'f^ 


\ 


^7 


"Nw^ 


\ 


/^ 


Fig.  54. — Gangrene  of  the  gall-bladder  with  perforation.  Two 
apertvires  are  seen,  through  which  stones  escaped;  at  the  lower  left- 
hand  corner  a  stone  is  seen  presenting. 


Perforation  of   the  Gall-bladder  229 

completely  obstruct  it,  though  there  was  very  little 
space  indeed  for  bile  to  flow  by  its  side.  The  hepatic 
duct  was  much  dilated;  not  so  the  cystic  duct,  which 
was  much  reduced  in  length  and  looked  more  like  a 
foramen  than  a  duct.  There  was  no  trace  of  jaundice 
postmortem. 

Simon  (Trans.  Path.  Soc,  vol.  5,  p.  156)  quotes 
two  cases  from  St.  Thomas's  Hospital  where  a  process 
of  discharge  of  stones  from  the  gall-bladder  had  appeared 
to  be  in  progress  at  the  time  of  death.  In  one  (where- 
of the  specimen  is  preserved  in  the  Museum)  there  was 
found,  beyond  the  fundus  of  the  gall-bladder,  a  cyst, 
constructed  of  dense  cellular  tissue,  communicating  with 
the  gall-bladder  by  a  small  ulcerated  opening  and  com- 
pletely filled  in  its  interior  by  a  concretion  of  choles- 
terin.  In  another  of  such  transitional  cases  (Postmortem 
Book,  19  Oct.,  1850)  the  fundus  of  the  gall-bladder 
was  found  communicating,  by  an  ulcerated  opening  a 
quarter  of  an  inch  in  diameter,  with  a  cyst,  about  as 
large  as  a  pigeon's  egg,  formed  of  dense  cellular  tissue, 
coherent  with  the  abdominal  wall  anteriorly  and  filled 
with  irregular  masses  of  concrete  biliary  matter  and  small 
calculi. 

If  a  localised  abscess  should  form,  it  may  burrow 
extensively,  and  open,  at  its  further  end,  on  to  the  skin 
or  into  a  hollow  viscus.  Stones  ulcerating  through  the 
neck  of  the  gall-bladder  or  the  cystic  duct  may  cause 
subphrenic  or  retro-peritoneal  abscess,  and  the  discharge 
of  bile  or  of  stones  may  then  make  clear  the  origin  of 
the  disease. 

The    gall-bladder   when   ulcerating   may   become    ad- 


230  Perforation   of   the  Gall-bladder 

herent  to  the  stomach,  duodenum,  or  colon,  and  the  stone 
escapes  into  them  through  an  internal  biliary  fistula. 

Stones  may  ulcerate  into  the  portal  vein  from  the 
gall-bladder  or  any  of  the  ducts.  Four  at  least  of  such 
cases  are  recorded. 

These,  however,  are  all  chronic  manifestations  of  the 
perforation  of  the  gall-bladder.  In  rarer  cases  the 
perforation  may  be  acute,  and  the  gall-bladder  ruptures 
directly  into  the  general  peritoneal  cavity.  Of  this 
acute  perforation  two  forms  may  be  met  with;  in  the 
one  the  whole  peritoneal  cavity  is  at  once  invaded  and 
a  general  peritonitis  is  caused;  in  the  other,  more  com- 
mon in  traumatic  than  in  calculous  cases,  the  peritonitis, 
though  almost  equally  severe,  seems  to  be  limited  by 
the  mesocolon  and  adherent  omentum  to  the  right 
hypochondrium ;  the  bacilli  in  such  cases  have,  no  doubt, 
a  slighter  virulence.  The  symptoms  of  an  acute  per- 
foration of  the  gall-bladder  are  those  of  peritonitis  of 
a  severe  and  rapid  form,  recognised  in  some  as  beginning 
in  the  right  hypochondrium,  but  in  many  being  so  intense 
and  widespread  as  to  leave  the  point  of  its  origin  a 
matter  of  speculation. 

The  gall-bladder  when  examined  is  seen  to  present 
patches  of  ulceration  upon  its  inner  surface.  There 
may  be  one  large  ulcer,  similar,  as  Budd  pointed  out,  in 
many  of  its  attributes  to  the  perforating  ulcer  of  the 
stomach,  or  there  may  be  several  ulcers,  one  or  more  of 
them  being  almost  gangrenous  in  appearance,  and  ap- 
parently ready  at  any  moment  to  give  way.  The  relief 
of  tension  in  the  gall-bladder  as  a  result  of  the  perfora- 
tion has  probably  saved  these  from  rupture.     The  outer 


J^ 


s 


Fig.  55. — Same  as  Fig.  54,  viewed  from  the  mucous  surface. 


Diagnosis  231 

surface  of  the  gall-bladder  is  maroon  coloured  or  bright 
green,  and  shews  a  rent  or  a  circular  opening  or,  rarely, 
two  or  more  openings.  The  peritoneal  surface  is  covered 
more  or  less  imperfectly  with  layers  of  ochre-coloured 
fibrin,  which  may  be  thick  and  tough,  and  almost  of  the 
appearance  of  wash-leather.  The  peritoneum  around 
the  gall-bladder  is  intensely  inflamed,  and  upon  all  the 
coils  of  intestine  in  the  neighbourhood  layers  of  pale 
yellow  fibrin  are  adherent.  Bile  is  present,  as  a  rule, 
in  the  peritoneal  cavity,  being  absent  only  in  those 
cases  in  which  a  stone  occludes  the  cystic  duct.  Gall- 
stones may  be  found  in  the  peritoneal  cavity  or  in  the 
gall-bladder  or  in  both ;  there  may  be  few  or  there  may 
be  hundreds.  In  five  cases  treated  by  operation  a 
stone  was  found  in  a  rent  in  the  gall-bladder. 

The  rent  or  perforation,  as  a  rule,  is  at  the  fundus 
of  the  gall-bladder,  but  any  part  of  the  wall  may  suffer. 
The  edges  are  thin  and  ragged  and  torn. 

Diagnosis. — A  correct  diagnosis  has  been  made  in 
certain  cases  by  the  observation  of  preceding  phenom- 
ena of  gall-stone  disease.  In  cases  recorded  by  Naunyn, 
Kiister,  and  others,  gall-stone  colic  had  occurred.  In 
one  patient  attacks  of  abdominal  cramp  had  occurred 
and  had  been  attributed  to  lead  poisoning.  In  all  cases 
the  symptoms  were  ushered  in  by  pain.  The  pain 
resembles,  very  nearly,  that  caused  by  the  perforation  of 
a  gastric  ulcer;  indeed,  in  more  cases  than  one  such  a 
perforation  has  been  diagnosed.  The  pain  is  sudden 
in  origin  and  is  intense.  It  cannot  often  be  localised, 
but  is  said  to  spread  over  the  whole  abdomen.  Prostra- 
tion,   collapse,  and    vomiting   speedily    follow,    and    the 


232  Perforation  of  the  Gall-bladder 

abdomen,  at  first  rigid  and  tense,  becomes  distended, 
flatus  ceases  to  pass,  and  the  pulse  becomes  rapid,  fre- 
quent, and  perhaps  irregular.  After  a  few  hours  the 
patient  may  rally,  having  the  "interval  of  repose  "  seen 
in  all  forms  of  perforation  within  the  abdomen.  Jaun- 
dice may  appear,  but  is  never  deep  in  tinge.  The  ab- 
dominal distension  increases  progressively,  and  free 
fluid  is  discernible  in  the  peritoneal  cavity.  In  a  case 
related  by  Schabad  (Petersb.  med.  Woch.,  1896)  the 
patient  lived  twenty-five  days  after  the  time  of  the 
perforation  of  the  gall-bladder.  In  traumatic  rupture, 
where  presumably  the  bile,  in  the  absence  of  gall-stones, 
is  sterile,  the  duration  of  life  may  be  even  greater  than 
this.  In  St.  Bartholomew's  Hospital  Museum  there  is 
a  specimen  (2268)  of  a  gall-bladder  ruptured  by  the 
impact  of  the  abdomen  against  a  piece  of  timber;  the 
patient  lived  five  weeks,  dying  from  peritonitis.  Mr. 
Arbuthnot  Lane  records  a  case  (Lancet,  March,  1894) 
in  which  operation  five  weeks  after  the  rupture  of  the 
gall-bladder  and  the  free  escape  of  bile  into  the  peri- 
toneum was  successfully  performed. 

Treatment. — Apart  from  operative  treatment,  the  issue 
is  always  fatal.  The  earlier  the  operation,  the  greater 
will  be  the  chances  of  success,  though  cases  are  related 
when  life  has  been  saved  when  the  operation  has  been 
performed  two  and  even  three  days  after  the  catastrophe 
had  occurred.  Much  will  depend,  of  course,  upon  the 
virulence  of  the  infection.  The  only  bacteriological 
examination  made  up  to  the  present  is  that  recorded  by 
Neck,  the  bacillus  coli  being  the  solitary  organism  found. 

Mistaken  diagnoses   of  perforated  gastric  ulcer,   vol- 


Treatment  233 

vulus,  acute  intestinal  obstruction  due  to  a  band,  and 
strangulated  umbilical  hernia  have  been  made.  One 
remarkable  case  is  recorded  by  Kiimmell  in  which  a 
tumour  supposed  to  be  ovarian  became  acutely  inflamed, 
peritonitis  followed,  and  death  in  two  days.  The  tumour 
was  found  to  be  a  distended  gall-bladder. 

When  the  abdomen  has  been  opened  and  the  con- 
dition realised,  the  case  must  be  treated  on  the  ordinary 
surgical  principles.  All  stones  must  be  removed  and 
the  peritoneum  cleansed.  It  may  be  necessary  in  certain 
cases  to  remove  the  gall-bladder ;  in  other  cases  drainage 
alone  will  be  indicated.  Experience  is  too  slender  to 
permit  of  any  definite  rules  being  given. 

It  is  clear  that  as  soon  as  a  perforation  of  the  gall- 
bladder is  diagnosed,  operation  should  be  undertaken, 
for  the  risks  of  septic  infection  increase  w4th  the  lapse 
of  time. 

In  the  earlier  stages  bile  itself  has  little  infectivity, 
but  with  stagnation  of  the  inflammatory  exudation  into 
the  peritoneum,  and  increasing  interference  with  the 
absorption  of  fluids,  the  culture  medium  becomes  con- 
stantly improved  and  the  bacteria  acquire  an  increasing 
virulence.  In  all  probability  cholecystectomy  followed 
by  free  drainage  will  prove  to  be  the  safest  method  of 
treatment. 

Surgical  treatment  has  been  adopted  in  fifteen  cases, 
including  two  of  my  own  cases.  The  subject  is  so  im- 
portant and  so  little  understood  that  a  brief  epitome 
of  the  recorded  cases  is  given. 

Case  I,  operated  on  in  1881  by  Schonbom,  reported 
by  Naunyn  (Naunyn,  Klinik  der  Cholelithiasis,  p.  83)  as 
follows : 


234  Perforation  of  the  Gall-bladder 

F.,  fifty  years,  had  suffered  some  months  from  severe 
gall-stone  colic  with  icterus;  stones  not  found.  In  one 
attack  sudden  abatement  of  the  colicky  pain,  with  severe 
collapse;  some  hours  later  most  violent  but  now  diffuse 
abdominal  pain,  severe  vomiting,  abdominal  distension, 
rapidly  increasing  free  peritoneal  exudation.  On  the 
third  day  following  Prof.  Schonborn  performed  laparot- 
omy at  my  request.  An  incision  was  made  about  lo 
cm.  long  in  the  median  line,  betw^een  the  umbilicus  and 
the  symphysis,  and  through  this  was  evacuated  a  large 
quantity  of  slightly  bile-stained  serous  pus.  Drainage 
of  abdominal  cavity.  After-course  favourable,  uninter- 
rupted by  any  relapse.  Patient  lived  eight  years  longer 
in  good  health,  without  any  further  symptoms  of  chole- 
lithiasis. 

Case  2. — (Kuster,  1884,  Congress  der  deutsch.  Ge- 
sellschaft  f.  Chir.,  1887.)  F.,  aged  fifty-seven.  Patient 
had  had  several  attacks  of  gall-stone  colic,  without  dis- 
charge of  stones  being  observed.  On  Nov.  26th  (even- 
ing) violent  diarrhoea  with  pain  in  neighbourhood  of 
gall-bladder,  increasing  in  severity.  Small,  rapid  pulse; 
cold  sweat  on  face  and  body ;  gall-bladder  neighbour- 
hood painful  and  tender  on  pressure.  There  was  severe 
vomiting;  morphia  injections  gave  ease  to  the  pain  but 
did  not  produce  sleep.  Next  midday  pain  became  most 
violent,  and  distension  and  sensitiveness  of  abdomen  were 
observed.  In  the  afternoon  of  the  next  day  the  vomit 
was  coloured  brown,  the  pulse  was  weaker,  there  was 
slight  icterus,  and  bile-pigment  w^as  seen  in  the  urine. 
In  the  evening  an  enema  was  given  without  result ;  the 
vomiting  continued  and  became  fceculent. 

The  abdominal  distension  continued  and  increased. 
Lavage  of  stomach,  which  yielded  evil-smelling  brown 
fluid,  gave  some  relief.  Next  day  the  condition  was 
much  the  same,  the  pulse,  which  had  been  weak,  increas- 
ing in  tension.    A  second  washing  out  of  the  stomach  took 


Treatment  235 

place  and  operation  was  then  decided  on.  The  diagnosis 
was  not  absolutely  certain,  though  gall-bladder  disease 
could   hardly  be   doubted. 

Operation :  Nov.  29th.  Abdomen  opened  in  the  middle 
line  from  ensiform  process  to  umbilicus.  Free  bile  was 
seen  between  reddened  and  distended  coils  of  intestine, 
pointing  to  origin  of  the  disease.  By  means  of  a  trans- 
verse incision  across  the  first  incision  the  neighbour- 
hood of  liver  was  exposed,  and  the  gall-bladder  was  found 
to  be  rather  small;  bile  flowed  away  from  the  fundus. 
The  opening  was  small  and  partly  obstructed  by  a  stone, 
which  w^as  plainly  the  cause  of  ulceration  and  rupture. 
The  opening  was  widened,  the  stone  removed,  and  the 
ulcerated  wall  cut  aw^ay  on  every  side  into  sound  tissue. 
The  gall-bladder  remnant  was  then  closed  after  careful 
cleansing  with  a  double  row  of  sutures  of  fine  catgut. 
The  abdominal  cavity  was  most  thoroughly  cleansed, 
and  the  abdominal  wound  was  closed  with  several  rows 
of  sutures.  The  effect  of  operation  was  but  temporary, 
symptoms  of  peritonitis  soon  returning  in  their  former 
severity.  Death  twenty-four  hours  after  operation.  No 
postmortem  allowed. 

Case  3. — (Jenner-Verrall,  Brit.  Med.  Journal,  1897,  ii, 
341).  The  patient  (F.,  forty-four)  had  frequently  suf- 
fered from  gall-stone  colic  with  jaundice.  For  four  days 
previously  there  had  been  frequent  vomiting  and  pain 
in  upper  abdomen.  Purgatives  gave  some  relief,  but 
the  abdominal  distension  continued.  "  Facies  perito- 
nealis"  present.  There  was  a  resistant  area  in  neighbour- 
hood of  gall-bladder.  An  incision  was  made  in  the  mid- 
dle line  of  abdomen.  Coils  of  intestine  presented,  covered 
with  bile-stained  fluid  and  fibrin.  A  perforation,  about 
f  cm.  in  diameter,  was  found  on  the  under  surface  of  the 
gall-bladder.  Gall-stones  were  found  in  bladder,  and  a 
large  number  removed.  The  cystic  duct  appeared  free. 
No   gall-stones    were    found    in   abdorninal   cavity.     On 


2.^6 


Perforation  of  the  Gall-bladder 


account  of  its  friability,  the  gall-bladder  was  closed  with 
great  care  by  sutures  which  passed  through  all  layers 
of  wall.  A  second  row  of  (Lembert's)  sutures  was  passed 
over  the  first.  All  careful  precautions  as  to  drainage 
and  plugging  with  gauze  were  taken.  First  stool  passed 
thirty-six  hours  after  operation.  Gradual  subsidence 
of  abdominal  distension  and  remission  of  fever.  Patient 
discharged  cured  after  forty-four  days. 

Case  4. — Allmann,  1897  (Allmann,  Ueber  Perforation 
der  Gallenblase  in  die  Bauchhohle,  Wiener  med.  Wochen., 
Nos.  25,  26,  1899).  Patient,  M.,  aged  forty- two.  There 
had  been  previous  frequent  attacks  of  colic  w^hich  had 
been  mistaken  for  lead  colic.  Another  violent  attack  was 
experienced  six  days  before  the  patient  came  into  hos- 
pital. The  abdomen  was  sensitive  to  pressure  in  neigh- 
bourhood of  gall-bladder.  An  injection  of  morphia  gave 
temporary  relief.  Next  morning  there  were  violent 
pain  and  slight  collapse.  Abdominal  distension  and  con- 
stipation were  present.  Abdominal  section  was  carried 
out  forty-eight  hours  from  beginning  of  illness.  An 
incision  was  made  parallel  with  the  right  costal  arch, 
one  fingersbreadth  below  it.  The  presenting  intestines 
were  distended  and  covered  with  somewhat  \-iscid  fluid 
and  here  and  there  with  small  clots.  The  gall-bladder 
was  small  and  very  shrivelled;  on  its  anterior  surface 
there  was  a  perforation,  the  opening  being  about  the 
size  of  a  cherry  kernel;  in  it  the  stone  was  fixed.  No 
stones  were  found  in  the  abdominal  cavity.  Chole- 
cystectomy was  performed.  The  cystic  duct  was  liga- 
tured and  the  peritoneum  sutured  over  the  stump. 
Abdominal  cavity  drained  with  strips  of  iodoform  gauze, 
and  the  wound,  except  at  the  point  where  the  iodoform 
gauze  was  projected,  was  sutured  with  three  rows  of 
stitches.  In  the  evening  patient's  condition  was  fair; 
he  vomited  once  in  the  evening  and  twice  in  night; 
hiccough  was  present  the  following  morning.     Abdomen 


Treatment  237 

was  much  distended  and  most  sensitive  to  pressure. 
The  abdominal  cavity  was  again  opened,  as  it  was  clear 
that  septic  peritonitis  was  present,  and  some  fluid  which 
had  collected  in  Douglas'  pouch  was  mopped  out.  The 
patient  died  next  morning.  The  gall-bladder  was  re- 
moved and  found  to  be  packed  with  stones,  and  a  larger 
stone  was  found  impacted  in  the  cystic  duct. 

Case  5. — (Allmann,  loc.  cit.,  1897.)  F.,  fifty-three. 
Suddenly  attacked  with  violent  pain  in  neighbourhood 
of  liver,  and  repeated  vomiting  of  yellowish  material; 
jaundice  not  present.  There  had  been  two  similar 
attacks  previously.  When  the  patient  came  into  hos- 
pital she  was  suffering  from  dyspnoea  and  was  without 
fever;  the  pulse  was  small  and  frequent;  the  abdomen 
was  distended,  on  left  especially.  Palpation  showed 
greater  resistance  in  right  hypochondrium,  commencing 
within  right  mammary  line,  and  especially  under  costal 
arch,  with  great  sensitiveness  to  pressure.  Percussion 
revealed  dulness  corresponding  to  area  of  resistance.  A 
diagnosis  of  perforation  of  gall-bladder  being  made, 
laparotomy  was  performed.  An  incision  was  made  from 
the  ensiform  cartilage  parallel  to  the  right  costal  margin. 
The  peritoneum  appeared  everywhere  inflamed,  reddened, 
and  covered  with  bile-stained,  viscid  fluid.  The  gall- 
bladder, nowhere  adherent,  was  small  and  perforated. 
Nine  gall-stones  were  found  between  coils  of  intestines. 
The  abdominal  cavity  was  cleansed  with  tampons,  and 
the  gall-bladder  was  sutured.  The  abdominal  cavity 
was  plugged  with  iodoform  gauze  in  direction  of  gall- 
bladder, and  drained  with  iodoform  gauze  in  dift'erent 
directions.  The  abdomen  was  sutured  up  to  the  point 
from  which  the  gauze  projected.  Next  day  the  patient 
was  better,  but  hiccough  and  abdominal  distension  per- 
sisted; on  the  day  following  the  vomiting  and  hiccough 
ceased  and  the  pulse  was  less  rapid.     On  third  day  dis- 


238  Perforation  of  the  Gall-bladder 

charge  of  flatus.     All   drainage  ceased  by  seventeenth 
day;    on  twenty-fifth  the  patient  discharged  cured. 

Case  6. — (Hochenegg,  Ein  Fall  von  Perforation  der 
Gallenblase  gegen  die  freie  Bauchhohle,  geheilt  durch 
Operation,  Wiener  klin.  Wochen.,  No.  21,  1899.)  P., 
forty-five.  Patient  admitted  Jan.  26,  1899.  Two  days 
previously  the  patient  had  vomited  after  a  heavy  meal. 
The  vomiting  was  violent,  and  the  ejecta  consisted  of 
food  and  later  of  bile.  Symptoms  of  illness  not  ascribed 
to  presence  of  gall-stones.  On  Jan.  26th,  after  an  ener- 
getic forward  movement,  there  came  on  suddenly  violent 
abdominal  pain,  collapse,  and  constantly  increasing  symp- 
toms of  peritonitis.  These  were  followed  by  abdominal 
distension.  Intestinal  obstruction  due  to  volvulus  of 
sigmoid  flexure  was  suspected.  After  some  hours  a 
tense  swelling  appeared,  giving  tympanitic  percussion 
sound,  and  was  regarded  as  a  twisted  coil  of  intestine. 
Temperature  normal ;  pulse  96  ;  diaphragm  stationary ; 
respiration  frequent.  There  was  an  umbilical  hernia 
which  was  for  the  most  part  reducible.  Aluch  sensitive- 
ness in  region  of  upper  abdomen.  The  abdomen  was 
opened  in  middle  line;  the  transverse  colon  was  seen 
to  be  enormously  distended.  In  the  attempt  to  free 
the  omentum  from  it  two  litres  of  yellowish,  viscid, 
bile-stained  fluid  escaped  from  the  upper  part  of  the 
abdomen.  In  the  gall-bladder,  at  about  the  middle,  was 
found  a  rent  about  i  cm.  long  by  ^  cm.  wide,  partly 
blocked  by  a  stone  which  was  blackish  brown  in  colour. 
From  the  perforation  bile  was  slowly  trickling ;  the  gall- 
bladder was  of  normal  size  though  the  wall  was  thick- 
ened ;  it  was  not  infiltrated  with  bile  nor  inflamed.  The 
rent  was  sutured  and  a  fresh  opening  made  at  the  fundus. 
From  here  seven  stones  about  size  of  hazelnut  were 
removed.  The  abdominal  cavity  was  cleansed  and  the 
fundus  of  the  gall-bladder  traced  to  the  abdominal  wall; 
a  drainage-tube  was  inserted  in  the  gall-bladder.     Two 


Treatment  239 

strips  of  iodoform  gauze  were  introduced  into  abdominal 
cavity,  and  rest  of  laparotomy  wound  closed.  After 
eight  days  the  tampon  was  removed  from  abdominal 
cavity;  after  fourteen  days,  the  drainage-tube.  In 
another  six  days  the  gall-bladder  fistula  was  closed. 
On  thirty-second  day  patient  discharged  cured. 

Case  7.— (Konig,  Deut.  med.  Woch.,  1902,  No.  7.) 
A  w^oman,  until  then  healthy,  was  taken  ill  late  one 
evening  with  internal  pain  and  vomiting,  etc.  The 
stomach  was  found  to  be  distended,  sensitive  to  pressure, 
with  painful  swelling,  the  size  of  a  hand,  to  right  of  um- 
bilicus. Volvulus  was  suspected.  On  reception  into 
hospital  there  were  noted  a  rather  wasted  appearance, 
a  foul  tongue,  and  occasional  sickness.  Later,  no  sick- 
ness, but  hiccough.  No  spontaneous  passage  of  faeces; 
abdomen  unevenly  swollen,  mostly  on  the  right  and  some- 
what beneath  the  umbilicus ;  here  there  was  slight 
resistance.  There  was  everywhere  sensitiveness  to  pres- 
sure, and  the  peristaltic  movement  of  intestines  was 
neither  visible  nor  audible.  When  the  abdomen  was 
opened  in  the  middle  line,  an  omental  cord  which  pro- 
ceeded from  region  of  umbilicus  to  inner  right  inguinal 
ring  was  seen  and  was  ligatured  off.  The  fluid  in  ab- 
domen was  distinctly  bile  stained,  and  on  extension  of 
incision  upwards  over  umbilicus  blood  coagula  were 
visible  on  reddened  intestinal  loops,  and  in  several  places 
large  dark  gall-stones.  The  ascending  colon  was  fixed 
by  numerous  old  adhesions.  The  gall-bladder  was  found 
to  be  unusually  large,  lengthened,  and  thickened  on  its 
inner  side;  about  two  fingersbreadths  from  the  fundus 
a  rent  was  visible,  surrounded  by  blood  coagula;  the 
opening  was  about  the  size  of  the  tip  of  the  finger,  and 
was  closed  by  a  round  brown  gall-stone.  A  transverse 
incision  was  now  made  in  the  right  rectus  muscle.  The 
gall-bladder  contained  several  stones;  the  ducts  were 
free   from  them.     The  general  abdominal  cavity  was  en- 


240  Perforation  of   the  Gall-bladder 

tirely  free  of  pus.  The  gall-bladder  was  separated  from 
liver  and  removed  with  several  stones.  The  abdominal 
cavity  was  cleared  of  gall-stones  which  lay  near  the  rent, 
and  the  abdominal  wound  was  closed  without  either 
drainage  or  tamponading.  On  second  day  after  opera- 
tion there  was  slight  but  distinct  icterus.  During  the 
first  two  days  the  pulse  (128)  and  the  temperature  (on 
one  day  up  to  38°  C.)  were  raised.  Then  both  declined. 
Flatus  passed  on  the  day  after  operation.  The  wound 
healed  without  reaction  so  that  patient  got  up  at  end 
of  three  weeks  and  could  go  home. 

Case  8. — (Von  Arx,  Ueber  Gallenblasenruptur  in  die 
freie  Bauchhohle,  Correspondenzblatt  f.  Schweizer 
Aerzte,  Nos.  19  and  20.)  F.,  forty-eight.  Patient  had 
had  some  pain  for  eight  months ;  there  was  a  violent 
attack  on  March  23,  1902,  and  again  another  attack  two 
months  later ;  in  both,  cramp  and  vomiting ;  and  in  the 
last,  constipation  after  severe  diarrhoea.  On  May  14th 
the  gall-bladder  was  palpable  to  below  the  umbilicus. 
Morphia  and  opium  gave  relief  for  one  day.  On  May 
15  th,  after  a  vain  attempt  at  defsecation,  the  patient 
became  aware  of  something  suddenly  giving  way.  There 
were  alarming  pain,  meteorism,  and  vomiting.  An  in- 
jection of  morphia  was  given.  The  tumour  was  no 
longer  palpable.  There  was  no  jaundice.  About  twenty 
hours  after  the  onset  of  perforation  a  median  incision 
was  made.  There  was  a  copious  outflow  of  mucous 
bile  with  shreds  of  fibrin  from  abdominal  cavity,  and  bile 
was  seen  between  the  coils  of  intestines  which  were  in- 
jected, distended,  and  adherent.  The  gall-bladder  was 
wholly  collapsed,  non-adherent,  and  its  wall  was  thick- 
ened. Below,  at  the  neck  of  bladder,  was  a  perforation 
2  cm.  in  length  with  necrotic  edges;  just  behind  it  was 
found  a  stone  the  size  of  a  nutmeg.  The  fundus  was 
opened;  the  stone  extracted.  Freshening  of  superficial 
openings  and  suture  of  same.     Abdominal  cavity  cleansed 


Treatment  241 

with  hot,  sterile  saHne  solution.  Drain  with  tampon 
inserted  in  gall-bladder,  which  was  sutured  to  the  parietal 
peritoneum ;  an  iodoform  gauze  drain  was  placed  below 
the  bladder.  The  patient  recovered,  and  at  the  time 
of  publication  of  this  case  the  biliary  fistula  was  com- 
pletely closed. 

The  following  case  is  recorded  by  Mr.  G.  P.  Newbolt 
(Lancet,  May  31,   1902,  p.   1534): 

Case  9. — A  married  woman,  aged  forty-eight,  was 
seen  on  March  15th.  She  was  very  ill,  and  evidently 
had  some  grave  abdominal  lesion.  She  had  suffered 
for  some  years  from  attacks  of  dyspepsia  but  had  never 
had  haematemesis  or  jaundice.  For  about  a  week  before 
she  had  dyspepsia  and  for  two  nights  had  not  slept  on 
account  of  the  pain  referred  to  the  umbilicus.  During 
this  time  she  had  only  taken  a  little  liquid  food.  At 
10  A.  M.  on  March  15th  she  was  seized  with  agonising  pain 
at  the  umbilicus  which  caused  her  to  double  up  and 
collapse.  Three  hours  later  the  pulse  was  no,  feeble 
and  compressible ;  the  abdomen  was  not  distended,  but 
was  hard  like  a  board  and  tender  all  over,  and  her  tem- 
perature was  102°.  The  liver  dulness  was  present. 
The  abdomen  was  opened  in  the  middle  line  above  the 
umbilicus.  Yellow,  turbid,  serous  fluid  was  seen  amongst 
the  coils  of  small  intestine.  Thorough  examination  of 
the  stomach,  back  and  front,  revealed  no  perforation, 
and  so  it  was  distended  with  a  pint  of  water  passed 
by  means  of  an  oesophageal  tube.  The  fluid  did  not 
escape.  The  incision  was  therefore  enlarged  down  below 
the  umbilicus.  On  introducing  the  hand  into  the  right 
flank,  a  large  gall-stone  was  felt  in  the  cystic  duct,  and 
a  much  distended  gall-bladder,  adherent  to  the  liver, 
which  was  enlarged.     There  was  a  minute  hole  in  the 

gall-bladder  from  which  thin,  puriform  fluid  was  escap- 
16 


242  Perforation  of   the  Gall-bladder 

ing.  A  transverse  incision  was  made  into  the  right  loin ; 
the  gall-bladder  was  exposed  and  opened  freely  and  six 
large  stones  were  removed,  one  being  impacted  in  the 
cystic  duct.  It  was  necessary  to  cut  away  the  sloughing 
part  of  the  gall-bladder,  which  was  behind  and  to  the 
inner  side  of  the  fundus ;  the  edges  were  then  inverted 
and  sewn  over,  completely  closing  the  cavity.  Having 
thoroughly  cleansed  the  abdominal  cavity,  a  gauze  pack 
was  left  in  leading  down  to  the  gall-bladder,  and  the 
right  flank  was  drained  by  placing  a  tube  below  the 
kidney.  The  patient  stood  the  operation  well  and  pro- 
mised at  first  to  make  a  good  recovery;  she  sank,  how- 
ever, five  days  after  the  operation,  apparently  from  ex- 
haustion. There  were  troublesome  vomiting  and  slight 
distension  unrelieved  by  salines  or  enemata. 

The  following  case  is  recorded  by  Lediard  (Lancet, 
July  4,  1903,  p.  21): 

Case  10. — The  patient  was  a  female,  aged  forty-seven, 
who  suftered  from  jaundice,  fever,  and  tenderness  in  the 
region  of  the  gall-bladder.  Attacks  of  biliary  colic  had 
lasted  on  and  off  for  three  years,  but  generally  yielded 
to  hot  applications  and  opium,  and  were  not  followed 
by  jaundice,  bile-stained  urine,  or  chalky  stools.  When 
I  first  saw  her,  on  i\Iarch  26th,  the  abdomen  was  flat,  but 
when  I  went  to  operate  upon  her  gall-bladder  a  week 
later,  the  abdomen  was  swollen  and  a  tumour  of  the 
size  of  an  adult  head  existed  in  the  middle  line  of  the 
abdomen,  the  highest  point  of  distension  being  rather 
below  the  umbilicus.  It  was  clear  that  something  had 
altered  the  appearance,  and  in  consequence  the  incision 
planned  was  changed  to  a  cut  in  the  middle  line  over  the 
swelling.  On  reaching  the  peritoneum,  matted  omentum 
and  recent  peritonitis  were  met  with,  and  on  passing 
the  finger  upwards  towards  the  liver,  a  gush  of  thick 


Treatment  243 

yellow  bile  escaped  over  the  wound  to  the  amount  of 
some  half  a  dozen  ounces.  On  swabbing  the  discharge 
the  upper  surface  of  the  liver  was  seen  lying  outside 
the  gall-bladder.  After  the  bile  had  been  removed  with 
swabs  I  enlarged  the  perforation  with  scissors  and  re- 
moved thirteen  small  gall-stones,  packed  the  gall-bladder 
with  gauze,  and  cleaned  the  abdomen.  The  perforation 
was  invaginated  and  stitched  with  Lembert's  sutures, 
one  suture  passing  through  the  edge  of  the  liver,  owing 
to  rottenness  of  the  gall-bladder  wall.  The  entire  ab- 
domen was  now  flushed  out  with  salt  solution,  and  the 
wound  was  then  closed  absolutely.  The  patient  suffered 
from  shock  and  had  a  subnormal  temperature  for  a  few 
days  and  was  fed  rectally  for  some  five  days,  but  made 
a  TOod  recoverv. 


The  three  following  cases  are  recorded  b}^  Neck;  the 
notes  of  the  last  two  having  been  sent  to  him  by  Wiegel 
of  Nuremberg: 

Case  II. — F.,  forty-two.  Patient  admitted  on  August 
28,  1902.  The  illness  had  begun  with  gastric  catarrh, 
vomiting,  and  finally  severe  and  general  abdominal  pain. 
Umbilicus  distended  and  very  painful.  Peritonitis  was 
present.  The  diagnosis  lay  between  strangulated  um- 
bilical hernia  and  disease  of  gall-bladder.  The  patient 
had  suffered  from  general  malaise  and  vomiting  for  three 
days,  and  also  from  pain  below  the  right  costal  arch 
and  about  the  umbilicus.  On  the  morning  before  her 
admission  her  pain  became  suddenly  worse ;  it  extended 
all  over  the  abdomen,  which  was  much  distended.  Res- 
piration became  rapid,  and  there  were  all  the  signs  of  a 
sudden  peritonitis.  It  was  probable  that  there  was  some 
affection  of  the  gall-bladder,  but  an  absolutely  certain 
diagnosis  was  not  possible,  owing  to  the  presence  of  a 


244  Perforation  of  the  Gall-bladder 

small  umbilical  hernia  which  might  prove  to  be  strangu- 
lated. These  were  the  circumstances  that  led  to  the 
abdomen  being  opened  in  the  middle  line.  As  nothing 
was  found  in  the  hernial  sac,  the  gall-bladder  was  ex- 
amined, and  disease  of  the  gall-bladder  was  indicated 
by  the  presence  of  the  peculiar  mucous  (though  not  bile- 
pigmented)  pus,  coming  from  the  right  side  of  the  ab- 
domen. 

Operation:  The  abdomen  was  opened  in  middle  line 
by  an  incision  commencing  at  ensiform  process  and 
terminating  5  cm.  below  umbilicus.  An  umbilical  hernia 
about  size  of  plum  was  opened.  Neither  intestine  nor 
omentum  w^as  found  in  the  hernia  sac,  but  muco-puru- 
lent  fluid  in  large  quantity  was  evacuated  from  right 
side  of  abdomen.  The  presenting  coils  of  intestine 
were  all  reddened  and  markedly  distended;  on  some 
coils  to  the  right  were  seen  fibrinous  layers  in  patches. 
By  means  of  an  oblique  incision  above  the  umbilicus 
taking  a  course  parallel  to  the  right  costal  arch,  the  re- 
gion of  the  gall-bladder  was  laid  open.  It  was  here 
specially,  between  the  intestinal  coils  of  the  right  side 
of  the  abdomen,  that  the  mucous  pus  was  present.  The 
gall-bladder  was  not  increased  in  size;  at  the  fundus 
there  was  a  perforation  of  the  diameter  of  a  pea;  its 
edges  were  thin  and  irregular.  The  lower  surface  of 
liver  as  well  as  part  of  stomach  w^as  covered  with  fibrin. 
From  the  orifice  of  the  gall-bladder  only  a  little  pus  was 
evacuated. 

The  abdominal  cavity  was  cleared  of  the  muco-puru- 
lent  contents  as  far  as  possible  by  sponging;  no  gall- 
stones were  found  in  it.  The  gall-bladder  was  isolated 
by  gauze  compresses,  and  the  opening  already  present 
in  it  was  slightly  enlarged  after  it  had  been  found,  by 
sounding,  that  there  were  gall-stones  present  in  the 
bladder.  No  stone  was  seen  in  the  perforation  opening. 
Twelve    facetted    gall-stones,    size    of    hazelnut,    were 


Treatment  245 

extracted.  No  flow  of  bile.  Mucous  membrane  much 
swollen,  coloured  dark-red,  showing  ulcers  at  several 
points.  An  attempt  was  made  to  stitch  the  gall-bladder 
to  the  abdominal  wall,  but  owing  to  the  friability  of  the 
walls  the  stitches  cut  through.  A  tube  was  introduced 
into  the  gall-bladder  and  the  wound  was  left  unsutured. 
The  patient  slowly  recovered,  bile  ceasing  to  flow  from 
the  wound  at  the  end  of  the  fifth  week. 

Case  12. — M.,  forty-five  years  old,  who  had  had  for 
years  numerous  attacks  of  gall-stone  colic,  and  on  this 
account  was  treated  medically  in  different  ways.  Patient 
had  also  visited  Carlsbad.  On  August  2  2d  he  had  severe 
tearing  pain  in  right  side  of  abdomen.  After  this,  severe 
pain  over  the  whole  abdomen  set  in.  The  pulse  was 
very  small  and  rapid.  Perforation  of  gall-bladder  was 
suspected.  Dr.  Wiegel  was  called  in  to  operate.  The 
pulse  w^as  rapid  and  small.  The  abdomen  was  as  hard 
as  a  board  and  very  sensitive  to  touch. 

In  the  abdominal  cavity  was  a  quantity  of  blood, 
partly  coagulated,  partly  fresh.  Between  the  intestinal 
loops  were  numerous  gall-stones.  The  gall-bladder  was 
enormously  enlarged — to  about  the  size  of  a  goose's  egg. 
On  the  side  of  it,  adjoining  the  under  surface  of  the 
liver,  was  a  rent  about  6  cm.  long  which  had  passed 
through  the  whole  wall  of  the  gall-bladder.  The  tear 
was  bleeding  severely.  Haemorrhage  was  stayed  by 
pressure.  Afterwards  the  gall-bladder  was  opened  in 
the  fundus.  After  opening  it  was  found  to  be  filled  with 
coagulated  blood.  All  the  stones  and  blood  clots  were 
evacuated  from  the  abdominal  cavity,  and  gall-stones 
were  removed  from  the  gall-bladder  and  cystic  duct. 
Afterwards  the  gall-bladder  was  packed  with  gauze,  and 
the  fundus  of  the  gall-bladder  was  sewn  to  the  abdominal 
wound.  A  drainage-tube  was  inserted  and  the  abdominal 
wound  was  partially  closed  by  suture.  Saline  infusion. 
After  the  operation  the  pulse  rose  a  little.     On  the  next 


246  Perforation  of   the  Gall-bladder 

day  general  condition  was  bad;  towards  evening  signs 
of  peritoneal  irritation  set  in.  Death  followed  on  August 
25th,  with  symptoms  of  peritonitis. 

Case  13. — F.,  aged  forty-two.  Patient  stated  she  had 
suffered  from  "catarrh  of  stomach"  three  years  pre- 
viously. For  some  years  past  had  had  pain  nightly 
in  right  side  of  abdomen.  Present  illness  (1903)  com- 
menced w4th  severe  rigor  at  midday,  lasting  two  hours. 
Towards  evening  violent  pain  set  in  on  right  side  of 
abdomen.  Some  jaundice  supervened,  varying  in 
amount.  Stools  regular.  On  September  5th,  sudden 
accession  of  pain  in  great  severity.  Jaundice  increased 
and  pain  became  general  over  abdomen  during  next 
five  days,  up  to  reception  of  patient  into  hospital.  Stools 
ceased  two  days  before  admission.  Flatus  was  not 
passed,  and  vomiting,  which  became  faecal  in  odour,  set 
in. 

The  usual  signs  of  peritonitis  were  predominant,  the 
abdomen  becoming  tense,  distended,  and  sensitive  to 
touch,  especially  so  beneath  right  costal  arch.  Abdom- 
inal dulness  from  free  effusion.  No  tumour  palpated. 
Respiration  hurried.  Pulse  126  per  minute  and  small. 
Temperature  38°. 

Three  hours  after  admission,  abdominal  section,  under 
chloroform,  incision  being  made  from  umbilicus  to  sym- 
physis pubis.  Bile-stained  fluid  evacuated.  Incision 
therefore  prolonged  upwards  over  umbilicus.  Above 
umbilicus  transverse  incision  to  right  made.  Large 
quantity  of  bile-stained  fluid  welled  up  every^vhere 
between  coils  of  intestine.  Gall-bladder  could  not  be 
located.  In  ductus  choledochus  was  felt  round  hard 
body  about  size  of  cherry  (gall-stone). 

On  account  of  patient's  bad  condition  radical  opera- 
tion not  undertaken,  iodoform  gauze  strips  being  in- 
serted in  abdominal  cavity.  Abdominal  wound  closed 
by  suture  in  middle  line.     Opening  made  for  drainage 


Treatment  247 

in  right  lumbar  region.  Saline  infusion  injected  and 
camphor  administered  subcutaneously  every  two  hours. 
Next  day  pulse  stronger,  but  more  frequent  (126). 
Vomiting  ceased,  but  distension  still  persisted. 

Change  of  bandage  on  September  13,  as  bandages  were 
soaked  with  bile.  Abdomen  still  distended  and  sen- 
sitive to  touch.  One  attack  of  vomiting,  and  for  first 
time,  still  of  liquid  consistency  and  whitish-grey  colour. 

Plugging  changed  September  i6th.  General  improve- 
ment in  condition  from  this  date  up  to  October  8th,  when 
general  symptoms  of  gall-stone  colic  (violent  pain,  rigor, 
vomiting,  etc.)  returned  with  accession  of  icterus.  At- 
tacks continued  to  October  13th. 

Operation  undertaken  under  chloroform  for  attempt 
to  remove  stone  impacted  in  ductus  choledochus.  Granu- 
lations of  wounds  pared  off.  Wounds  wiped  with  iodo- 
form tincture.  Rectangular  incision  made,  one  side  of 
which  reached  from  middle  line  above  umbilicus  to 
the  right  as  far  as  prolongation  of  anterior  axillary  line; 
the  other  took  a  course  downwards  to  the  centre  of 
abdomen.  Triangular  flap  thus  formed  folded  back, 
and  adhesions  between  parietal  peritoneum,  omentum, 
colon,  liver,  and  stomach  detached.  Between  stomach 
and  liver  was  found  layer  of  tissue  about  i  mm.  in  thick- 
ness, which  might  have  been  either  organised  pseudo- 
membrane  or  remnant  of  degenerated  gall-bladder. 
On  pressure  with  blunt  instrument  inwards,  clear  bile 
fluid  was  evacuated  from  this  region.  Layer  of  tissue 
above  mentioned  was  removed.  At  lower  surface  of 
liver,  portion  of  tissue  of  similar  appearance  remained 
behind.  Gall-bladder  could  not  be  located  with  cer- 
tainty. After  stomach  had  been  detached  from  liver 
it  was  possible  partially  to  unfold  ligamentum  gastro- 
hepaticum  (lesser  omentum),  and  by  separating  the 
adhesions  behind  it  to  introduce  finger-tip  into  bursa 
omentalis.     Round  hard  stone,  size  of  cherry,  in  chole- 


248  Perforation  of  the  Gall-bladder 

dochus  was  now  felt;  it  was  easily  movable,  now  slipping 
behind  duodenum,  now  upwards  to  ductus  hepaticus. 
It  was  finally  fixed  and  cut  down  upon.  Incision  of 
about  3  cm.  had  to  be  made.  After  removal  of  stone 
abundant  flow  of  bile.  India-rubber  tube  introduced  into 
hepatic  duct,  over  which  the  choledochus  wound  was 
closed,  up  to  point  of  exit  of  tube,  by  means  of  thread 
and  catgut  suture.  Plugging  with  iodoform  gauze  around 
drainage-tube. 

Towards  evening  there  was  secretion  of  bile  in  larger 
quantity  through  drainage-tube.  Patient  vomited  but 
once  after  operation,  and  then  no  more.  Secretion  of 
bile  through  drainage-tube  gradually  diminished  and 
then  ceased.  Patient  left  hospital  with  abdominal 
bandage  and  free  from  discomfort  on  November  26th. 

Case  14. — The  following  case  was  recorded  by  me  in 
the  British  Medical  Journal,  November  8,  1902: 

Phlegnwiwus  Cholecystitis:  Perforation  of  Gall-blad- 
der.— M.  A.,  aged  forty-six;  male.  Patient  seen  with 
Dr.  Erskine  Stuart,  Batley.  Had  been  perfectly  well 
up  to  December  31,  1900.  On  that  day  he  had  a  sharp 
attack  of  pain  in  the  right  hypochondriac  region  about 
an  hour  after  his  evening  meal.  He  felt  sick  and  cold, 
vomited  several  times,  and  could  only  obtain  ease  by 
doubling  himself  over  the  back  of  a  chair.  He  was 
given  a  large  dose  of  opium  and  put  to  bed.  The  next 
day  he  was  slightly  jaundiced;  the  day  following  more 
so,  and  the  jaundice  has  persisted.  Pain  in  the  right 
hypochondrium  has  been  constant — relief  had  only  been 
obtained  b}'  opium  administrations. 

On  examination,  January  11,  1901,  the  patient  was 
found  moderately  jaundiced  and  looking  ill.  The  ab- 
domen was  full  and  prominent;  the  whole  right  hy- 
pochondriac region  was  hard,  strongly  resisting,  tender 


Chronic  Perforation  of  the  Gall-bladder        249 

on  pressure.  The  muscular  protection  was  so  effective 
that  no  deep  examination  was  possible.  A  diagnosis 
of  cholangitis  and  cholecystitis,  depending  possibly  upon 
calculus,  was  made.  The  rigidity  and  tenderness  were 
supposed  to  be  due  to  a  localised  peritonitis,  possibly 
dependent  upon  distension  of  the  gall-bladder  as  a  result 
of  obstruction  of  the  cystic  duct. 

The  abdomen  was  opened  on  January  12  th  by  an 
incision  through  the  right  rectus  muscle.  On  opening 
the  peritoneum  bile-stained  liquid  with  flocculent  masses 
of  lymph  flowed  from  the  wound.  At  the  least  three 
pints  of  fluid  were  removed.  A  collection  was  found 
between  the  liver  and  the  diaphragm,  the  fluid  there 
being  thick  and  semi-purulent.  An  examination  of  the 
gall-bladder  disclosed  the  cause  of  the  condition.  The 
gall-bladder  w^as  thickly  coated  with  lymph,  was  deep 
purple  in  colour,  and  showed  a  sloughing  opening  on 
its  surface  from  which  bile-tinged  fluid  was  oozing.  The 
opening  was  about  one  and  a  quarter  inches  in  diameter ; 
its  edges  were  ragged  and  a  little  thickened.  In  the 
gall-bladder  seven  stones  were  found ;  an  eighth,  the 
largest,  was  discovered  later  in  the  upper  part  of  the 
renal  pouch,  partly  buried  in  lymph.  The  cavity  was 
cleaned  up  as  well  as  possible,  the  gall-bladder  opening 
trimmed,  and  a  drainage-tube  secured  in  it;  the  sub- 
phrenic abscess  was  separately  drained  and  a  tube  was 
also  passed  in  through  a  stab  wound  in  the  loin. 

The  patient,  whose  condition  was  bad  before  the 
operation,  died,  gradually  declining  in  forty-eight 
hours. 


Many  cases  of  chronic  perforation  of  the  gall-bladder, 

with  abscess,  have  been  recorded.  As  a  rule,  the  abscess 
cavity  lies  between  the  gall-bladder  and  the  abdominal 
wall,  and  it  is  only  after  the  evacuation  of  the  pus  that 


250  Perforation  of   the  Gall-bladder 

gall-stones  are  found  and  a  rent  in  the  gall-bladder  dis- 
covered. 

The  following  interesting  case  is  recorded  by  Wendel 
(Annals  of  Surgery,  vol.   27,  p.   199): 

The  patient,  a  woman,  twenty-three  years  of  age,  had 
an  extremely  movable  ovoid  tumour  in  the  upper  part 
of  the  mesogastric  and  left  lumbar  regions;  the  lump 
was  five  inches  in  length  and  three  inches  in  breadth; 
it  was  clearly  cystic.  The  patient  was  seen  on  several 
occasions,  and  on  each  the  tumour  was  found  in  a  differ- 
ent position  in  the  abdomen.  After  nine  months  a 
tender  swelling  was  found  in  the  right  hypochondrium. 
There  had  been  a  sudden  seizure  of  severe  pain  in  the 
right  iliac  region,  faintness,  vomiting,  high  fever,  and 
abdominal  distension.  Operation  was  declined,  and  the 
patient  gradually  recovered  from  her  serious  condition, 
but  six  months  later  she  consented  to  operation  on 
account  of  the  distress  caused  by  the  lump  in  her  side. 
An  incision  was  made  in  the  right  semilunar  line,  over 
the  most  prominent  part  of  the  swelling.  As  the  knife 
penetrated  the  thickened  peritoneum,  pus  welled  up 
freely,  the  opening  was  enlarged,  and  several  ounces  of 
stinking  pus  and  several  gall-stones  were  evacuated. 
The  finger  defined  an  abscess-cavity  communicating  with 
the  gall-bladder,  which  had  a  perforation  about  one 
inch  in  length  and  one-half  inch  in  breadth  on  the  pos- 
tero-external  aspect  of  its  body.  The  viscus  was  filled 
with  gall-stones.  The  gall-bladder  was  loosened  from 
the  adhesions,  a  portion  of  the  adherent  omentum  tied 
off  and  removed.  The  cystic  duct  was  found  to  be 
one-eighth  inch  in  diameter,  three  and  a  quarter  inches 
in  length  from  the  anterior  border  of  the  liver  to  the 
neck,  and  very  much  twisted.  The  peritoneal  invest- 
ment of  the  duct  presented  a  mesenteric  development 


Chronic  Perforation  of  tlie  Gall-bladder        251 

about  two  inches  in  length,  which  was  attached  to  the 
inferior  surface  of  the  liver.  The  neck  of  the  gall- 
bladder was  obstructed  by  the  largest  of  the  concretions. 
The  duct  was  divided  at  the  anterior  border  of  the 
liver,  inverted,  closed  with  a  fine  catgut  suture;  the 
peritoneum  was  finally  closed  over  the  stump.  The  sac 
contained  213  gall-stones. 

I  have  operated  upon  the  following  case: 

The  patient  was  a  female,  aged  thirty-nine,  who  was 
admitted  to  the  Infirmary  under  my  care.  She  had 
suffered  for  years  from  attacks  of  pain  accompanied  by 
vomiting  and  soreness  of  the  body.  There  had  never 
been  jaundice  nor  any  symptoms  which  were  attributed 
to  gall-stones.  Hcematemesis  was  said  to  have  been 
observed  on  two  occasions.  While  in  the  Infirmary 
she  was  seized  with  an  acute  attack  of  pain  with  rigor, 
a  temperature  of  104°,  collapse,  and  vomiting.  The 
abdomen  was  a  little  distended  and  there  were  exquisite 
tenderness  and  rigidity  over  the  gall-bladder  area.  Her 
condition  improved  rapidly,  but  a  stiffness  of  the  ab- 
domen remained.  The  upper  part  of  the  right  rectus 
was  rigid  for  the  four  days  which  intervened  between 
this  attack  and  the  operation.  I  opened  the  abdomen 
through  the  right  rectus  and  found  the  gall-bladder 
inflamed  and  adherent.  On  separating  the  omentum 
from  its  inner  side  an  abscess  cavity  about  the  size  of 
a  hen's  egg  was  disclosed,  and  in  this  five  small  gall- 
stones were  lying.  The  opening  into  the  gall-bladder 
would  admit  a  lead  pencil.  It  was  near  the  fundus.  I 
enlarged  the  opening  and  trimmed  its  edges.  Over  sixty 
stones  were  removed  from  the  gall-bladder.  A  drainage- 
tube  was  introduced  into  the  gall-bladder  and  a  separate 
gauze-drain  was  placed  in  the  abscess  cavity.  The  pa- 
tient made  a  speedy  recovery. 


CHAPTER  VIII. 
INTESTINAL  OBSTRUCTION  DUE  TO  GALL-STONES. 

The  obstruction  of  the  intestine  by  a  gall-stone  is 
an  infrequent  occurrence.  At  the  Leeds  General  In- 
firmary, where  probably  more  cases  of  gall-stones  are 
operated  upon  than  in  any  other  British  hospital,  we 
have  had  only  one  case  during  the  last  ten  years. 

Barnard  (Annals  of  Surgery,  August,  1902)  found  that 
during  eight  consecutive  years  360  cases  of  intestinal 
obstruction  were  operated  upon  at  the  London  Hospital ; 
among  these  were  eight  examples  of  gall-stone  ileus. 
The  proportion  of  cases  of  obstruction  due  to  gall-stones 
to  other  forms  is  said  by  Fitz  to  be  i  to  13,  by  Leichten- 
stem,  I  to  28.  The  average  age  of  patients  is  from  fifty- 
five  to  sixty  years,  and  women  are  affected  five  times 
more  frequently  than  men,  the  youngest  being  twenty- 
seven  (Path.  Soc.  Trans.,  vol.  i,  p.  255).  In  120  cases 
obser\'ed  by  Naunyn,  five  patients  were  under  thirty, 
seven  between  thirty  and  forty,  and  ninety-six  between 
forty-one  and  sixty.  The  gall-stone  which  causes  the 
obstruction  may  ulcerate  through  the  gall-bladder  into 
the  stomach,  very  rarely  (Jeafferson,  British  Medical 
Journal,  May  30,  1868),  the  duodenum;  most  commonly, 
the  jejunum  or  the  colon.  Cysto-duodenal  fistulas  are 
more  frequent  than  all  other  forms  of  gall-bladder  fis- 
tulas.    Naunyn,  in  30  fatal  cases,  found  a  duodenal  per- 

252 


Intestinal  Obstruction  Due  to  (jall-stones      25, 


f oration  in  28,  and  a  perforation  into  the  colon  in  the 
remaining  two.  The  passage  of  a 
stone  from  the  gall-bladder  into 
the  duodenum  is  obviously  more 
likely  to  cause  obstruction  than 
the  passage  into  the  colon.  In 
rare  cases  the  gall-stone  may  have 
passed  down  the  common  duct, 
which  is  then  considerably  dilated. 
Such  a  case  is  recorded  by  Aber- 
crombie,  who  says:  "The  com- 
mon duct  was  enlarged  so  as  easily 
to  admit  a  finger."  (Diseases  of 
the  Stomach,  etc.,  p.  134.)  The 
following  brief  notice  is  recorded 
by  Lynn  Thomas : 


"A  gall-stone  passed  through 
the  common  bile-duct  without  giv- 
ing rise  to  obstruction,  and  got 
impacted  in  the  ileum  about  one 
yard  from  the  ileo-cascal  valve, 
and  caused  death  from  obstruc- 
tion within  three  days.  I  got  it 
through  an  insurance  company 
questioning  the  cause  of  death  of 
a  man  who  was  struck  on  his  right 
side  whilst  getting  into  a  dogcart 
through  his  horse  running  away; 
slight  umbilical  pain  came  on  at 
once,  and  passed  oft'  for  a  short 

time,  to  recur  and  develop  within  twenty-four  hours  into 
a  case  of  acute  intestinal  obstruction.     I  made  the  ne- 


FiG.  56. — Two  large 
and  articulated  calculi 
which  were  passed  nat- 
urally. The  larger  meas- 
ured one  and  a  half 
inches  in  extrenle  diame- 
ter, and  w^eighed  250 
grains;  it  has  a  second 
facet,  indicating  the 
presence  of  a  third  cal- 
culus From  a  lady, 
aged  forty,  who  recov- 
ered after  seventeen 
days'  symptoms  of  in- 
testinal obstruction. 
She  lived  fourteen  years 
afterwards  (Royal  Col- 
lege of  Surgeons'  Mu- 
seum, No.  2830  d). 


254      Intestinal  Obstruction  Due  to  Gall-stones 

cropsy  nine  years  ago ;  no  operation  had  been  performed. 
The  stone  is  remarkable  as  being  conico-cylindrical  in 
shape,  like  a  pom-pom  shell;  it  is  one  and  five-eighths 
inches  in  diameter  and  its  point  had  travelled  in  front. 
There  were  no  adhesions  around  the  gall-bladder  and  bile- 
duct." 

Leichtenstern  and  other  writers  have  recorded  cases 
of  blockage  of  the  bowel  by  concretions  which  consisted 
of  a  gall-stone  nucleus  and  a  laminar  deposit  of  salts. 
The  very  great  majority  of  gall-stones  which  cause 
obstruction  have  passed  through  a  fistulous  communica- 
tion between  the  gall-bladder  and  the  duodenum.  The 
stone  may  obstruct  the  duodenum,  the  jejunum,  the 
ileum,  the  sigmoid  flexure,  rarely  the  colon.  The  small 
intestine  from  the  duodeno-jejunal  angle  to  the  ileo- 
cecal valve  gradually  narrows  in  calibre.  A  stone 
therefore  which  causes  obstruction  high  up  in  the  je- 
junum will  be,  as  a  rule,  larger  than  a  stone  which  blocks 
the  ileum  near  its  termination. 

If  a  stone,  therefore,  escapes  from  the  duodenum,  it 
will  most  probably  be  arrested  near  the  ileo-caecal  valve. 
In  32  cases  quoted  by  Leichtenstern  the  stone  was  found 
in  the  duodenum  or  jejunum  in  10  cases,  in  the  middle 
ileum  in  5  cases,  in  the  lower  part  of  the  ileum  in  17 
cases. 

Courvoisier  found  the  obstruction  in  the  duodenum 
and  jejunum  in  21.4  per  cent,  of  cases;  in  the  ileum  in 
65.4  per  cent. ;  at  the  ileo-caecal  valve  in  10  per  cent. ;  and 
in  the  sigmoid  flexure  in  2.4  per  cent.  In  rare  instances 
the  stone  may  cause  symptoms  of  obstruction  by  becom- 
ing impacted  in  the  colon  (Korte,  Berl.  khn.  Woch., 
1893,   p.    690)    or  in  the   sigmoid  flexure. 


Intestinal  Obstruction  Due  to  Gall-stones       255 

The  obstruction  in  the  majority  of  instances  is  due 
to  the  actual  plugging  of  the  bowel  by  the  calculus. 
When  the  gut  is  opened,  the  stone  seems  to  lie  upon  a 
sort  of  diaphragm  which  is  caused  by  the  sudden  nar- 
rowing of  the  gut  at  the  lower  margin  of  the  stone,  for 
the  bowel  below  the  obstruction  is  generally  quite  flaccid, 
thin,  and  empty.  It  would  seem  that  in  exceptional 
instances  a  volvulus  may  be  due  directly  or  indirectly 
to  the  blocking  of  the  intestine  by  a  gall-stone.  The 
following  instances  are  recorded  by  Mayo  Robson  (Trans. 
Royal  Med.-Chir.  Soc,   1895,  p.   117): 

Case  I. — "Acute  intestinal  obstruction  in  a  woman 
of  sixty-eight;  operated  on  November  12,  1890,  by 
laparotomy.  On  the  eighth  day  of  the  obstruction  a 
volvulus  of  the  small  intestine  was  discovered  and  un- 
twisted. Bowels  moved  by  enema  on  the  sixteenth  day 
after  onset  of  obstruction  and  eighth  day  after  opera- 
tion, and  a  large  gall-stone,  three  inches  in  circumference 
and  one  and  three-eighth  inches  long,  was  passed,  this 
being  manifestly  the  cause  of  the  obstruction  and  second- 
arily of  the  volvulus.  The  patient  returned  home  on 
the  twenty-sixth  day  and  remained  quite  well  when 
heard  of  a  year  subsequently." 

Case  2. — "On  March  13,  1894,  I  received  a  telegram 
asking  me  to  go  prepared  to  operate  on  a  case  of  acute 
intestinal  obstruction.  I  found  a  Mrs.  O.,  aged  sixty- 
two,  suffering  from  acute  obstruction  of  six  and  faecal 
vomiting  of  two  days'  duration,  the  onset  having  started 
like  a  gall-stone  attack,  with  pain  over  the  gall-bladder, 
and  later  in  the  umbilical  region.  She  gave  a  history 
of  having  suffered  from  attacks  of  gall-stones  for  several 
years,  some  of  which  had  been  followed  by  jaundice; 
and  from  the  mode  of  onset  of  the  present  seizure,  and 


256      Intestinal  Obstruction  Due  to  Gall-stones 

the  slight  jaundice  following  it,  she  was  quite  sure  the 
attack  had  been  one  of  her  old  seizures  at  the  commence- 
ment. From  the  persistence  of  the  fsecal  vomiting,  the 
presence  of  visible  intestinal  peristalsis,  and  the  pinched 
and  anxious  countenance,  with  the  absence  of  relief  by 
ordinary  medical  means,  operation  was  decided  upon. 
Laparotomy  was  performed,  and  volvulus  of  the  small 
intestine  being  found,  the  loop  of  gut,  which  was  much 
congested,  was  untwisted  and  the  abdomen  closed. 
Flatus  passed  the  same  day  and  the  bowels  were  opened 
the  next.  The  wound  healed  by  first  intention  and  re- 
covery was  uninterrupted." 


The  following  remarkable  example  of  impaction  of  a 
stone  in  the  duodenum  is  recorded  by  Meisel  (Miinch. 
med.  Woch.,  1900,  No.  7).  A  woman,  forty-three  years 
of  age,  had  suffered  for  three  months  with  signs  of  dila- 
tation of  the  stomach  and  pyloric  stenosis.  When  the 
stomach  was  washed  out,  remnants  of  food  taken  eight 
days  before  were  found.  Wasting,  acute  pain,  more 
especially  after  food,  and  vomiting  were  the  chief  symp- 
toms, and  a  large  movable  tumour  was  felt  by  the  patient 
herself  through  her  lax  abdominal  wall.  The  abdomen 
was  opened  under  the  expectation  of  finding  a  carcino- 
matous growth  at  the  pylorus.  The  tumour  was  found 
to  be  due  to  a  large  gall-stone  impacted  in  the  beginning 
of  the  duodenum.  Mikulicz  (Archiv  f.  klin.  Chir.,  Bd.  51) 
found  that  duodenal  obstruction  in  one  case  was  due 
to  the  pressure  of  gall-stones  lying  in  a  diverticulum 
from  the  cystic  duct.  Several  stones  were  superim- 
posed and  their  pressure  had  greatly  narrowed  the  lumen 
of  the  duodenum. 


Symptoms  257 

The  narrowest  part  of  the  bowel  from  the  pylorus  to 
the  anus  is  at  the  ileo-cascal  valve.  The  valve  may 
cause  the  arrest  of  a  stone,  or  may  be  ruptured  or  damaged 
by  its  passage.  Thus  Maclagan  (Trans.  Clin.  Soc.,  vol. 
21,  p.  87)  records  a  case  in  which  a  woman,  after  four 
attacks  of  intestinal  obstruction,  passed  spontaneously 
four  large  gall-stones,  each  one  inch  in  diameter,  and  at 
the  postmortem  only  the  fringes  of  the  ileo-ceecal  valve 
remained.  It  would  appear  that  the  gall-stone  may,  by 
the  irritation  of  its  rough  surface,  induce  a  spasm  of 
the  bowel,  and  thus  cause  intestinal  blocking,  for  Duplay 
and  Reclus  state  that  on  postmortem  examination  the 
stone  has  often  been  found  lying  quite  loose  in  the  flaccid 
intestine.  Israel  has  recorded  a  case  of  obturation  due 
to  a  gall-stone  whose  largest  diameter  was  barely  three- 
quarters  of  an  inch;  muscular  spasm  was  considered  a 
potent  factor  causing  the  obstruction.  The  conditions 
present  in  a  case  of  gall-stone  ileus  differ  from  those 
present  in  most  cases  of  intestinal  obstruction.  There 
is  a  block  in  the  lumen  of  the  bowel,  but  there  is  no 
interference  with  the  circulation.  The  experiments  of 
Kader  have  shewn  clearly  that  the  intensity  and  severity 
of  the  symptoms  of  strangulation  are  in  no  small  measure 
due  to  the  interference  with  the  vascular  supply  of  the 
involved  loop.  In  gall-stone  ileus  we  have  to  reckon 
only  with  a  plugging  of  the  lumen. 


SYMPTOMS. 
The  symptoms  of  intestinal  obstruction  due  to  gall- 
stones vary  within  the  widest  possible  limits.     They  are 
17 


258      Intestinal  Obstruction  Due  to  Gall-stones 

most  intense  and  of  greatest  urgency  in  those  cases  in 
which  the  duodenum  is  blocked  or  the  upper  part  of  the 
jejunum;  they  are  subdued  and  of  the  type  present  in 
chronic  intestinal  obstruction  when  the  sigmoid  flexure 
is  affected,  or  when,  as  in  one  case  related  by  Ord,  the 
stone  is  caught  in  the  rectum  just  above  the  internal 
sphincter.  In  the  majority  of  cases  the  stone  is  impacted 
in  the  ileum  and  a  definite  clinical  picture  can,  therefore, 
be  drawn  to  illustrate  the  average  case. 

A  history  of  previous  attacks  of  gall-stone  colic  may 
be  obtained,  but  generally  there  is  no  mention  made  of 
jaundice  as  one  of  the  symptoms.  The  stone,  as  we  have 
seen,  generally  makes  its  way  through  the  wall  of  the 
gall-bladder  directly  into  the  duodenum;  there  is  no 
interference  with  the  free  passage  of  bile,  and,  as  a  rule, 
there  is  no  cholangitis.  In  only  about  one-fifth  of  the 
recorded  cases,  so  far  as  my  reading  goes,  was  an  un- 
doubted history  of  regular  cholelithiasis  obtained  before 
or  after  the  operation. 

The  onset  of  symptoms  is  usually  abrupt.  There  is 
a  sudden  seizure  of  acute  abdominal  pain,  attended  either 
by  faintness  or  nausea.  Vomiting  occurs  soon,  increases 
quickly,  both  in  quantity  and  frequency,  and  is,  in  all 
cases,  the  most  conspicuous  and  the  most  distressing 
symptom.  The  character  of  the  ejected  fluids  alters 
in  appearance  every  few  hours.  At  first  the  vomit  is 
green,  deeply  bile  stained,  and  contains  a  little  mucus. 
Soon  it  becomes  turbid,  dark-yellow  or  brownish  in 
colour,  and  has  a  faint,  sickly  smell.  Within  twenty- 
four  hours  there  is  an  unmistakable  sour,  offensive, 
almost  fseculent  odour,  and  shortlv  afterwards  the  vomit 


Symptoms  259 

is  recognised  as  consisting  of  the  contents  of  the  small 
intestine,  and  is  usually  described  as  being  stercoraceous. 
Schliller  found  that  "faecal  vomiting"  was  present  in 
77  out  of  120  cases.  The  vomiting  is  decidedly  more 
severe  when  the  obstruction  is  high  in  the  jejunum,  and 
is  then  unremitting  and  exhausting.  When  the  block 
is  lower,  there  are  less  distress  and  less  urgency.  The 
quantity  of  fluid  that  may  be  ejected  is  astonishingly- 
large.  Dr.  Pye  Smith  has  related  a  case  in  which,  when 
the  upper  jejunum  was  blocked,  ten  pints  were  vomited 
within  forty-eight  hours. 

After  the  initial  shock  has  passed  off,  the  symptoms, 
apart  from  the  vomiting,  are  by  no  means  so  intense  as  in 
other  forms  of  small  intestine  obstruction.  The  pain  is 
generally  slight  and  continuous,  but  there  are  often  in- 
tense, though  transient,  exacerbations.  During  these 
attacks  of  colic  there  may  be  faintness  and  collapse. 
In  most  cases  the  obstruction  is  not  at  once  complete. 
Flatus  is  passed  once  or  twice  and  the  bowels  may  act. 
Naunyn  emphasises  the  fact  that  flatus  may  be  passed 
even  at  the  time  that  the  vomiting  is  stercoraceous. 
Rarely  a  loose  motion  may  be  discharged,  or  there  may 
be  a  brisk  attack  of  diarrhoea.  Obstruction,  with  the 
passage  of  flatus  in  small  quantity,  once  or  twice,  is  the 
rule.  Abdominal  distension  is  rarely  present.  The 
greater  number  of  the  patients  are  women  over  fifty 
years  of  age,  in  whom  the  abdomen  is  fat,  flabby,  and 
pendulous.  Palpation  reveals  a  soft,  unresisting  ab- 
domen. Intestinal  coils  are  seen  only  in  the  chronic 
cases.  A  very  good  example  of  this  is  recorded  by  Eisner 
(Med.    News,    February,    1898,   p.    167).     There  is  little 


26o      Intestinal  Obstruction  Due  to  Gall-stones 

or  no  tenderness  on  examination.  In  rare  instances  the 
stone  has  been  felt  through  the  abdominal  wall  or 
on  rectal  examination.  (Eve,  Brit.  ]\Ied.  Journ.,  1895, 
vol.    I.) 

In  a  typical  case  of  gall-stone  ileus,  in  which  the 
stone  is  impacted  in  the  ileum,  the  following  will  be  the 
characteristic  signs  and  symptoms :  The  patient  is  gener- 
ally a  woman,  over  fifty  years  of  age,  and  of  full  habit 
of  body;  the  onset  of  symptoms  is  sudden;  pain  and 
slight  collapse  are  first  observed,  and  very  speedily, 
vomiting;  vomiting  is  incessant,  copious,  and  exhausting ; 
it  is  the  most  striking  feature  of  the  case;  the  ejected 
fluids  become  stercoraceous  in  about  twenty-four  to 
thirty-six  hours ;  obstruction  is  often  incomplete,  flatus 
or  even  faeces  being  occasionally  passed;  rarely,  there 
is  diarrhcea.  The  abdomen  remains,  as  a  rule,  soft  and 
flaccid. 

Though  this  is  the  type,  the  variations  from  it  are 
not  seldom  encountered.  The  following  illustrative  cases 
may  be  quoted: 


Eisner  (Med.  News,  1898,  p.  164)  records  the  case  of 
a  woman,  fifty-seven  years  of  age,  who  consulted  him 
in  March,  1895,  on  account  of  repeated  acute  pains  in 
the  upper  part  of  the  abdomen.  There  was  a  history 
of  gall-stone  colic  with  jaundice.  From  March  until 
July  progressive  emaciation  and  anorexia  were  observed ; 
there  were  repeated  attacks  of  pain,  but  no  calculi 
were  observed  in  the  stools.  On  July  5th  a  hard  swell- 
ing "about  the  size  of  a  hazelnut  was  palpable  near  the 
border  of  the  epigastric  and  right  hypochondriac  regions." 
A    diagnosis    of    pyloric    carcinoma    was    made.     There 


Symptoms  261 

was    constant   indigestion    and   the   stomach   was   very 
dilated.     Free  HCl  was  absent  on  all  occasions.     This 
condition    persisted    until    October,    1896,    a    period    of 
fifteen    months    from    the     discovery    of    the    tumour, 
which  was  always  palpable.     In  this  month  symptoms 
of  partial  intestinal  obstruction  were  manifested  and  the 
tumour  had   disappeared.     On   October   8th  there  was 
observed  a   "characteristic  coiling  of  a  portion  of  the 
intestine  into  a  sausage-shaped  mass  in  the  upper  part 
of  the  abdomen."     There  was  vomiting  of  a  dirty  green, 
at   times  brown   coloured,   sour-smelling  fluid.      A  few 
days  later  a  tumour  was  found  in  front  of  the  tense 
intestine,  and  was  equal  in  size  to  the  tumour  formerly 
palpable  in  the  epigastric  region.     A  diagnosis  of  gall- 
stone obstruction  was  then  made.     On  October  14th  the 
coiling  seemed  to  involve  the  whole  length  of  the  small 
intestine.     The  increase  in  coiling  seemed  to  justify  a 
delay  in  instituting  surgical  interference.     I  concluded 
that  obstruction  was  not  complete,  and  that  the  obstruct- 
ing mass  was  movable,  as  shewn  by  the  increased  length 
of  the  intestine  involved  from  day  to  day.     On  October 
1 6th  a  gall-stone  was  passed;    it  measured  five  and  a 
half  inches  in  circumference,  three  inches  in  length,  and 
its  weight  was  368  grains.     Eleven  months  later,  after 
an  attack  of  "acute  indigestion,"  a  second  gall-stone  was 
passed,  weighing  240  grains  and  measuring  three  inches 
in    circumference.     Since    the    passage    of    the    second 
gall-stone  the  patient  had  remained  quite  well. 

This  case  illustrates  several  interesting  points:  The 
error  in  the  diagnosis  of  the  tumour  felt  in  the  position 
of  the  pylorus;  the  discovery  that  the  "tumour"  was 
wandering;  the  intestinal  distension  which  w^as  recog- 
nised as  increasing  day  by  day,  and  finally  the  safe 
passage  of  so  large  a  stone.     Somewhat  similar  instances 


262      Intestinal  Obstruction  Due  to  Gall-stones 

are  related  by  Miles  (Lancet,   1861),  Hale  White  (Brit. 
Med.  Journ.,  vol.  2,  p.  903,   1886),  and  other  writers. 

In  other  recorded  cases  the  symptoms  of  obstruction 
have  recurred,  owing  to  the  blockage  of  the  gut  by  other 
stones.  Such  an  instance  is  recorded  by  Maclagan  (Clin. 
Soc.  Trans.,  vol.  21,  p.  87): 

The  patient,  a  lady  of  spare  habit,  sixty-three  years  of 
age,  was  seized  on  February  14th  with  a  severe  attack 
of  pain  in  the  abdomen,  accompanied  by  much  sickness 
and  nausea.  The  vomiting  was  peculiar,  the  ejected 
matter  exceeding  in  quantity  anything  that  could  have 
been  lodging  in  the  stomach;  it  came  up  without  any 
effort  in  large  quantities  and  evidently  consisted  of  the 
contents  of  the  small  intestine.  The  acute  symptoms 
lasted  five  days  and  then  passed  off.  On  ]\Iarch  4th 
a  similar  attack  occurred.  There  was  intense  griping 
pain  in  the  abdomen;  intense  nausea  and  occasional 
vomiting  were  present.  This  attack  passed  away,  and 
on  March  21st  another  attack  began,  characterised  by 
the  same  symptoms — vomiting,  constipation,  and  acute 
pain.  On  April  ist  there  was  a  fourth  attack;  on  April 
18th  she  passed  a  large  gall-stone,  nearly  an  inch  in 
diameter;  on  the  following  morning  a  second,  a  little 
over  an  inch  in  diameter;  the  next  day  she  passed  a 
third,  and  two  days  after,  a  fourth.  The  patient  grad- 
ually became  weaker  and  died.  At  the  postmortem  a 
free  communication  was  found  between  the  gall-bladder 
and  the  duodenum.  The  cystic  duct  was  obliterated. 
Dr.  ]\Iaclagan  sums  up  as  follows:  "It  will  be  observed 
that  the  illness  which  this  patient  had  consisted  of  four 
distinct  attacks,  characterised  by  acute  pain  in  the 
abdomen,  sickness,  nausea,  and  the  occasional  ejection 
by  the  mouth  of  the  contents  of  the  small  intestine. 
During  each   attack  the   bowels   ceased   to   act.     There 


Symptoms  263 

can  be  little  doubt  that  these  four  attacks  correspond 
to,  and  were  symptomatic  of,  the  passage  down  the 
small  intestine  of  the  four  gall-stones  which  she  subse- 
quently voided." 

The  symptoms  in  some  few  recorded  examples  have 
approached  in  indolence  and  quietude  those  due  to 
chronic  intestinal  obstruction.  The  following  case  is 
recorded  by  Everley  Taylor  (Lancet,  1895,  vol.  i,  p. 
867): 

The  patient,  a  woman  fifty-six  years  of  age,  had  been 
suffering  from  continuous  vomiting  for  thirty-six  hours 
when  first  seen.  On  examination,  a  rounded  swelling, 
slightly  movable  and  dull  on  percussion,  was  noticed. 
For  the  first  two  days  after  treatment,  morphine,  diet- 
ing, etc.,  was  begun;  the  vomiting  continued  incessantly. 
For  the  next  five  days  all  food  was  stopped.  During 
this  time  there  was  no  retching  or  nausea,  and  flatus  was 
passed.  On  the  twenty-sixth  day  the  abdomen  became 
distended,  no  flatus  passed,  and  the  vomiting  for  the 
first  time  became  stercoraceous.  Operation  was  decided 
upon;  the  abdomen  was  opened  and  a  gall-stone  found 
in  the  small  intestine  and  removed. 

Dr.  Wilkinson  gives  brief  notes  of  a  case  under  his 
own  care  (Mayo  Robson:  "Diseases  of  the  Gall-blad- 
der," etc.,  2d  ed.,  p.   loi): 

"  My  patient  is  a  lady  of  sixty-three,  and  the  facts  are 
briefly:  An  attack  of  acute  intestinal  obstruction, 
stercoraceous  vomiting,  etc.  Obstruction  lasted  three 
weeks,  giving  way  finally  under  rest,  opium,  and  copious 
enemata;   and  three  weeks  later  a  gall-stone  was  passed, 


264      Intestinal  Obstruction  Due  to  Gall-stones 

per  vias  naturales,  about  the  size  of  a  pigeon's  egg,  and. 
weighing  five  drachms  four  and  a  half  grains." 


PROGNOSIS. 

It  is  certain  that  a  spontaneous  recovery  may  be 
anticipated  far  more  frequently  in  cases  of  gall-stone 
ileus  than  in  any  other  form  of  acute  intestinal  obstruc- 
tion. Even  when  the  patient  has  been  ill  for  days  and 
is  brought  perilously  near  to  death,  recovery  may  ensue 
when  the  stone  is  passed.  Hutchinson  (Archives  of 
Surgery,  1892,  p.  9)  gives  notes  of  a  case  in  which  the 
symptoms  were  of  such  severity  that  on  the  sixth  day 
all  hope  of  recovery  was  abandoned,  and  it  was  expected 
that  the  patient  would  die  in  the  night.  The  following 
morning,  however,  improvement  set  in,  a  gall-stone  was 
voided,  and  complete  recovery  followed.  Other  similar 
instances  have  been  related.  At  times  the  symptoms 
may  be  acute,  the  pain  and  incessant  vomiting  most 
distressing  till  a  moment  when,  quite  suddenly,  ease  is 
experienced  and  recovery  is  assured.  It  is  not  difficult 
to  believe  that  at  such  a  time  the  stone  escapes  through 
the  ileo-caecal  valve  into  the  more  capacious  large  in- 
testine, presently  to  be  passed  by  the  rectum. 

The  frequency  with  which  an  attack  of  acute  obstruc- 
tion, due  to  gall-stones,  passes  off  with  complete  recovery 
has  been  variously  estimated.  Naunyn  considers  that 
over  50  per  cent,  of  patients  recover  under  the  expectant 
treatment — morphine,  enemata,  etc.  He  mentions  that 
in  a  series  of  thirteen  operations  only  one  terminated 
successfully.     He  further  points  out  that  frequently  the 


Prognosis  265 

obstruction  yields  after  seven  or  nine  days,  and  con- 
cludes that  operation  is  not  to  be  recommended.  Langen- 
buch  remarks  that  "Gall-stone  obstruction  is  a  surgical 
disease,  the  treatment  of  which  is  to  be  entrusted  to  the 
physician  only  during  a  very  short  period." 

The  various  museums  contain  very  large  stones  which 
have  been  safely  passed,  and  side  by  side  with  these  may 
sometimes  be  seen  smaller  stones  which  have  caused  fatal 
obstruction.  Fitz  (quoted  by  Hemmeter:  "Diseases  of 
the  Intestines,"  vol.  2,  p.  236)  collected  notes  of  23  cases 
of  gall-stone  obstruction.  Twelve  were  treated  medically, 
of  whom  eight  recovered,  and  eleven  surgically,  of  whom 
two  recovered.  The  passage  of  the  gall-stone  in  those 
cases  which  recovered  occurred  on  the  fourth,  fifth, 
sixth,  tenth,  fourteenth,  fifteenth,  seventeenth,  and 
twentieth  days.  Since  all  the  cases  operated  upon  after 
the  seventh  day  terminated  fatally,  and  as  five  cases 
under  medical  treatment  after  this  date  recovered,  Fitz 
is  of  the  opinion  that  the  condition  of  the  patient  must 
chiefly  determine  the  treatment  to  be  followed.  There 
can  be  no  doubt,  however,  that  in  many  patients,  as  is 
abundantly  confirmed  by  the  reading  of  recorded  cases, 
operation  is  only  advised  when  prolonged  medical  treat- 
ment has  proved  unavailing.  Under  such  conditions 
it  is  not  surprising  to  find  that  the  bowel  has  been  found 
gangrenous  at  the  point  of  blockage  or  above  it,  and  the 
general  intestinal  congestion  and  distension  above  the 
stone  of  the  most  marked  degree.  The  operation  is 
then  only  a  last  resort  in  a  case  in  which  death  was 
certain   and   imminent. 

If  a  sure  diagnosis  of  gall-stone  obstruction  could  be 


266      Intestinal  Obstruction  Due  to  Gall-stones 

made,  a  delay  of  two  or  three  days,  during  which  medical 
treatment  was  being  tried,  would,  in  some  cases,  permit 
of  the  passage  of  the  stone.  There  are,  however,  very 
few  cases  recorded  in  which  the  stone  was  passed  before 
the  fourth  day.  It  is  certain  that  the  best  results  would 
be  obtained  if  a  series  of  cases  could  be  treated  upon  the 
ordinary  principles  now  governing  the  treatment  of  all 
forms  of  acute  intestinal  obstruction — operation  at  the 
earliest  possible  moment  after  the  diagnosis  of  acute 
obstruction  has  been  definitely  made.  If  the  abdomen 
is  opened  in  a  case  of  gall-stone  ileus,  the  operation  is 
frequently  of  extreme  simplicity,  and  is  rapidly  per- 
formed. The  gall-stone  is  easily  found,  removed  by  a 
simple  incision,  and  the  resulting  wound,  barely  more 
than  an  inch  in  length,  can  be  securely  stitched  up  in 
less  than  five  minutes.  The  whole  operation  need  not 
occupy  more  than  twenty  to  thirty  minutes.  The  shock 
is  therefore  slight,  the  peritoneal  handling  trivial,  and 
the  exposure  of  the  intestines  of  the  briefest. 

Operations  performed  during  the  first  three  days 
would  probably  have  a  mortality  little,  if  at  all,  in  ex- 
cess of   lo  per  cent. 


TREATMENT. 

If  medical  treatment  be  advised,  it  will  consist  chiefly 
in  withholding  food  by  the  mouth,  in  the  administra- 
tion of  nutrient  enemata  hourly,  and  aperient  enemata 
once  daily,  and  in  the  injection  of  small  doses  of  mor- 
phine and  atropine  subcutaneously.  The  constant  vomit- 
ing may  be  relieved  by  occasional  lavage  of  the  stomach. 


Treatment  267 

If  operation  be  advised,  it  will  be  carried  out  with 
the  precautions  and  preparations  necessary  in  all  ab- 
dominal operations.  An  incision  just  large  enough  to 
admit  the  hand  is  made  between  the  umbilicus  and 
pubes.  When  the  peritoneum  is  opened,  the  caecum  is 
sought  and  the  terminal  portion  of  the  ileum.  This 
will  probably  be  found  collapsed.  The  empty  gut  is 
rapidly  passed  through  the  finger  till  the  stone  is  met. 
The  loop  containing  the  stone  is  then  withdrawn 
from  the  abdomen,  clamped  above  and  below,  or  nipped 
by  an  assistant's  fingers.  The  stone  is  then  removed 
by  an  incision  down  on  to  it  through  the  intestinal 
wall,  the  cut  being  of  such  length  as  the  size  of  the  stone 
demands.  If  the  bowel  below  the  stone  be  very  empty 
and  narrow,  the  stone  may  be  displaced  upwards  two 
or  three  inches,  into  a  distended  portion  of  the  gut,  to 
make  the  subsequent  suture  of  the  bowel  easier.  The 
stone  being  extracted,  the  incision  is  stitched  by  two 
layers  of  continuous  sutures,  the  bowel  cleansed  and 
replaced,  and  the  operation  completed  in  the  usual 
manner. 

The  gall-stone  may  be  pushed  onwards  into  the  large 
intestine  in  certain  cases,  as  in  the  following,  recorded  by 
Glutton : 

A  woman,  aged  seventy-six,  passed  a  large  gall-stone 
per  anum  with  symptoms  of  cholelithiasis,  including 
jaundice.  After  these  symptoms  had  subsided  a  tumour 
could  be  felt  in  the  position  of  the  gall-bladder,  but 
the  patient  remained  well  for  fifteen  months,  when  she 
was  suddenly  seized  with  severe  abdominal  pain,  vomit- 
ing,  and   other   symptoms   of  acute   intestinal   obstruc- 


268      Intestinal  Obstruction  Due  to  Gall-stones 

tion.  The  tumour  in  the  region  of  the  gall-bladder  was 
found  on  examination  to  have  vanished,  and  the  true 
cause  of  the  obstruction  was  suspected.  Laparotomy 
was  performed  and  a  conical  concretion  was  found  about 
eight  inches  from  the  lower  end  of  the  ileum,  which 
was  pushed  on  through  the  ileo-cascal  valve  without 
much  difficulty.  Five  days  later  it  was  passed  per 
anum,  after  some  trouble  with  the  rectum,  and  was 
found  to  consist  of  a  gall-stone  one  and  a  quarter  inches 
(3.1  cm.)  long  by  one  inch  (2.5  cm.)  broad,  and  three 
and  three-tenth  inches  (8.25  cm.)  in  circumference.  It 
had  one  large  facet  which  fitted  to  that  on  the  calculus 
passed  fifteen  months  previously. 

The  successful  result  in  this  case  was  due  mostly 
to  the  fact  that  the  operation  was  undertaken  only 
twenty -four  hours  after  the  onset  of  the  acute  symptoms, 
by  which  time  the  gut  around  the  stone  had  hardly 
had  time  to  become  much  injured.  The  manipulation 
of  the  stone  was  also  rendered  more  easy  by  its  narrower 
end  lying  nearer  the  valve  than  the  broad  end. 

C.  L.  Gibson,  in  a  study  of  646  cases  of  intestinal  ob- 
struction recorded  between  1888  and  1898,  found  that 
40  were  due  to  gall-stones  (Annals  of  Surgery,  October, 
1900,  p.  506);  of  the  40  cases,  21  died.  There  were  9 
males  and  27  females;  in  the  remainder  the  sex  is  not 
mentioned.  The  youngest  patient  was  thirty-five  years 
of  age;  only  seven  patients  were  under  fifty,  and  eight 
were  seventy  years  or  over. 

The  obstruction  was  only  once  found  below  the  ileo- 
csecal  valve;  once  the  stone  was  impacted  in  the  valve. 
In  21  cases  the  history  distinctly  states  the  site  of  its 


Treatment  269 

arrest  as  the  ileum;  in  two,  as  the  jejunum,  and  in  one 
at  the  junction  of  jejunum  and  ileum. 

There  was  a  clear  history  of  gall-stones  in  18  cases; 
in  five  cases  it  is  distinctly  stated  that  there  had  never 
been  any  suspicion  of  cholelithiasis. 

The  largest  stone  weighed  three  and  a  half  ounces. 


CHAPTER  IX. 

DETAILS  OF  PREPARATION  FOR  OPERATIONS  UPON 
PATIENTS   SUFFERING  FROM  GALL-STONES. 

Success  in  abdominal  surgery,  as  in  all  the  affairs 
of  life,  depends  very  largely  upon  the  observance  of 
details.  In  the  careful  examination  of  the  patient, 
with  reference  both  to  the  local  and  to  the  general  con- 
ditions; in  the  strict  preparation  for  a  few  days  before 
the  operation,  whenever  possible;  in  neatness,  rapidity, 
and  thoughtful  planning  of  the  operation — in  all  these 
there  lie  the  means  and  the  secret  of  success.  With 
few  exceptions,  the  same  technique  is  desirable  in  all 
operations.  I  propose  to  describe  the  details  which 
are  carried  out  in  mv  owm  operations,  first,  with  refer- 
ence to  the  surgeon,  assistants,  nurses,  instruments,  and 
dressings,  and,  secondly,  with  reference  to  the  patient. 


PREPARATIONS  ADOPTED  BY  THE  SURGEONS  AND 
ASSISTANTS. 

It  is  most  desirable,  it  is  even  more,  it  is  absolutely 
necessary,  that  for  the  proper  observance  of  cleanliness 
during  operations  the  surgeon  should  be  properly  clad. 
The  garments  which  are  suitable  for  daily  wear  are 
surgically  unclean  and  should  be  changed  by  all  those 
who  are  in  immediate  proximity  to  the  area  of  opera- 


Preparation  for  Operations 


271 


tion.  In  former  days  the  surgeon  felt  that  he  was  ade- 
quately prepared  for  an  operation  when  he  had  per- 
functorily turned  back  the  cuff  of  his  coat,  and  in  the 


Fig.   57. — Surgeon  prepared  for  operation. 


illustrations  of  all  the  older  works  on  surgery  (borrowed 
and  reproduced,  it  is  sad  to  say,  even  up  to  the  present) 
the  surgeon's  cuffs  and  links  are  neatly  depicted.     The 


2/2  Preparation  for  Operations 

removal  of  the  coat  and  the  wearing  of  a  special  coat — 
generally  an  old-fashioned  and  almost  worn-out  over- 
coat— were  considered  a  striking  improvement.  Such  a 
garment  was  worn  from  day  to  day,  and  becoming  more 
and  more  stiffened  by  freshly  added  splashes  of  blood, 
was  as  disreputable  and  as  greatly  prized  as  the  dilapi- 
dated gown  of  an  undergraduate.  I  can  still  recall  the 
thrill  of  excitement  and  the  murmur  -of  amusement 
that  greeted  the  appearance  of  the  first  white  operation 
coat  in  my  own  hospital.  To-day,  however,  the  surgeon 
should  be  clad  from  head  to  foot  in  spotless  sterilised 
garments.  A  sterilised  cap  is  worn  so  that  the  heads 
of  the  surgeon  and  his  assistant  when  they  meet  in  sharp 
contact  over  the  abdominal  wound  shall  not  scatter  hair 
and  dirt  broadcast.  A  sterile  coat  is  worn,  sterile  sleeves, 
and  boiled  rubber  gloves.  Sterilised,  or,  at  least,  newly 
washed  white  trousers  and  clean  shoes,  preferably  with 
rubber  soles,  are  worn.  Prepared  in  this  way  the  sur- 
geon is  safe  not  to  inflict  a  chance  infection  in  any  wound. 
All  parts  likely  to  be  near  the  wound  or  to  touch  it 
are  absolutely  clean. 

It  is  not  enough,  though  one  can  see  the  practice 
everv  day,  to  wash  the  hands  and  perhaps  the  forearms 
and  to  be  content  with  this.  When  instruments  are 
lying  on  a  towel  during  the  performance  of  an  opera- 
tion, the  surgeon  may,  in  some  manipulation,  allow  an 
unclean  elbow  or  arm  to  rest  for  a  few  moments  upon  an 
instrument,  and  presently  employ  that  instrument  again. 
The  operator  should  be  so  prepared  that  all  his  acces- 
sible surfaces  are  clothed  with  sterile  garments.  Exactly 
the  same  rules  apply  to  the  assistants  and  the  nurses. 


Hands  273 

There  should  be  no  uncovered  surfaces,  which,  by  con- 
tact, are  Hkely  to  cause  infection. 

Hands.— The  preparation  of  the  hands  should  be 
the  same  whether  gloves  are  worn  or  not.  It  is  almost 
impossible  to  over-emphasise  the  importance  of  thorough 
cleansing  of  the  hands  and  nails.  The  literature  of  this 
one  subject  alone  would  require  almost  a  life-time  for 
the  reading,  but  the  conclusions  of  all  investigators  are 
unanimous  in  stating  that  an  assured  and  absolute 
sterilisation  of  the  hands  is  impossible  to  obtain.  But 
there  can  be  no  question  that  a  sufficiently  near  approach 
to  perfection  can  be  attained  by  the  exercise  of  the 
greatest  care.  Professor  Kocher,  for  example,  whose 
results  are  at  the  least  the  equal  of  any,  operates  with 
bare  hands.  But  of  the  care  taken  by  him  to  ensure 
cleanliness,  all  those  who  have  seen  him  work  or  who 
have  read  his  book  will  realise.  It  could,  I  think,  be 
successfully  argued  that  of  all  the  details  in  the  prepara- 
tion for  an  operation  none  equals  that  of  the  cleansing 
of  the  surgeon's  hand. 

The  preparation  begins  with  a  thorough  washing  in 
soap  and  hot  water.  When  the  hands  and  arms  are 
socially  clean,  a  nail-brush  may  be  taken  and  a  thorough 
scrubbing  of  the  hands,  fingers,  and  nails  especially, 
is  begun.  Each  finger  and  each  nail  separately  scrubbed 
and  frequent  rinsing  in  water  as  hot  as  can  be  borne  is 
necessary.  If  possible,  running  water  should  be  used, 
but  failing  that,  a  series  of  basins  will  do  equally  well. 
After  prolonged  washing  in  one  basin,  a  second  is  used, 
and  a  third,  and  finally  a  fourth.  Each  basin  and  the 
water  which  it  contains  should  be  sterilised.  It  is  of 
18 


2  74  Preparation  for  Operations 

no  advantage  to  have  sterile  running  water  if  the  basin 
into  which  it  runs  is  a  fixed  basin,  which  cannot  be  ren- 
dered sterile ;  nor  is  it  possible  to  have  water  remain 
sterile  if  the  basin  in  which  it  fills  is  fixed  as  in  the  or- 
dinary lavatory.  Either  the  water  must  be  running 
continuously  and  allowed  to  flow  over  and  away  from 
the  hands  and  arms,  or  the  basin  and  its  contained 
water  must  each  be  easily  sterilisable.  The  washing 
must  be  carried  out  regardless  of  time.  After  at  least 
fifteen  minutes  of  soap  and  water  the  hands  and  nails 
may  be  scrubbed  with  sterile  gauze,  which  is  worked 
into  all  the  crevices  and  cracks  which  exist  on  every 
hand  and  finger.  After  this  some  antiseptic  application 
is  necessary.  The  best  is  alcohol  in  some  form  or  another. 
Eighty  per  cent,  of  alcohol  to  the  extent  of  two  or  four 
ounces  may  be  poured  over  the  hands,  rubbed  well 
over,  and  wiped  oft'  with  a  sterile  towel,  or  the  hands 
may  be  soaked  for  a  few  minutes  in  a  solution  of  spirit 
and  biniodide  of  mercury.  Instead  of  alcohol  a  watery 
solution  of  biniodide  of  mercury  i  :  2000  may  be  used, 
and  the  hands,  forearms,  and  elbows  allowed  to  soak 
therein  for  at  least  five  minutes  by  the  clock.  The  great 
disadvantage  of  all  antiseptic  preparations  for  the  hands 
is  the  undoubted  tendency  that  they  have  to  cause 
roughness.  This  rough  and  coarse  condition  of  the  skin 
makes  any  cleansing  very  much  more  tedious  and  any 
reasonable  sterilisation  very  difficult  of  attainment. 
In  these  matters  the  personal  idiosyncrasy  of  the  surgeon 
goes  for  much.  Some  operators  can  bear  mercury  com- 
pounds, others  are  immune  to  the  irritation  of  carbolic, 
but  all,  so  far  as  I  can  judge,  can  bear  to  use  alcohol 


Gloves  275 

preparations  better  than  any  other  antiseptic  agent. 
My  own  practice  is  to  wash  thoroughly  in  the  way  I 
have  described,  with  soap  and  hot  water,  to  use  gauze 
friction,  to  steep  for  a  few  minutes  in  i :  2000  biniodide, 
then  to  have  a  wash  over  with  alcohol,  and  finally  to 
rinse  well  in  sterile  salt  solution. 

Gloves. — It  is  now  my  invariable  practice  to  use 
rubber  gloves  during  operations.  At  the  first  I  found 
some  difficulty  in  working  in  them,  and  I  felt  clumsy 
and  inapt.  That  was  the  fault  of  the  gloves,  and  of  my 
want  of  knowledge  of  the  proper  method  of  putting  them 
on. 

I  now  use  7 J  light  rubber  gloves.  They  are  a  size 
smaller  than  my  ordinary  glove,  and  therefore  fit  fairly 
tight.  After  being  boiled  for  twenty  minutes  they  are 
put  on  in  the  following  way :  The  opening  in  the  glove 
is  held  stretched  wide  by  two  fingers  and  the  glove  is 
filled,  by  a  movement  of  "scooping,"  with  sterile  salt 
solution  which  fills  the  basin  in  which  the  gloves  lie. 
When  the  glove  is  nearly  filled  with  water  it  is  held 
in  one  hand  while  the  other  hand  gently  wriggles  into 
it.  As  the  hand  enters,  water  escapes  until  the  fingers 
have  reached  to  within  about  an  inch  of  the  tip.  Then 
the  other  glove  is  filled  and  put  on  in  exactly  the  same 
way.  The  further  pulling  on  of  the  gloves  is  impossible, 
but  they  may  be  made  to  go  on  by  rapidly  stroking  the 
glove  from  the  fingers  to  the  wrist  with  dry  sterile  gauze. 
The  glove  when  fully  on  should  fit  quite  tight,  but  should 
not  be  so  tight  as  to  hamper  the  movements  of  the 
hand.  The  outside  of  the  glove  should  never  be  touched 
with    the    opposite    hand,    which,    though    scrupulously 


2/6  Preparation  for  Operations 

prepared,  should  be  considered,  as  it  doubtless  is,  ca- 
pable of  infecting  the  glove  if  friction  be  used.  (See 
Kocher's    Operative    Surgers^    second   English   edition.) 

During  an  operation  the  glove-covered  hand  is  rinsed 
in  sterile  salt  solution  as  soon  as  soiled.  As  a  rule,  it 
is  easier  to  work  with  a  glove  which  is  wet  than  with 
one  which  is  dry,  for  when  dry,  the  gloves  are  apt  to 
stick  to  instruments,  ligatures,  and  swabs.  A  frequent 
rinsing  in  a  sterilised  solution  is  therefore  necessary. 
No  antiseptic  solution  is  ever  used,  and  none  is  permitted 
to  touch  the  peritoneum.  There  is  abundant  experi- 
mental evidence  to  shew  that  the  delicate  peritoneum 
is  seriously  damaged  by  contact  with  antiseptic  solutions, 
and  that  its  power  of  absorption  is  decidedly  lessened. 

During  an  operation  a  glove  may  be  pricked  or  torn 
by  a  needle  or  other  sharp  instrument.  This  is  more 
likely  to  happen  when  the  operator  is  unused  to  gloves; 
as  he  becomes  more  accustomed  to  them  and  has  cul- 
tivated a  slightly  altered  tactile  sense,  he  will  find  that 
an  injury  to  a  glove  is  rarely  caused.  If  the  prick  be 
on  a  finger,  a  finger  stall  or  a  finger  cut  from  another 
glove  which  has  been  partially  spoilt  must  be  used  to 
cover  the  damage.  This  should  be  done  at  once,  for 
if  the  glove  has  been  worn  even  for  a  few  minutes,  the 
hand  will  be  septic.  The  sweat  glands  and  the  deeper 
portions  of  the  skin  will  have  emptied  their  organisms 
on  to  the  surface  of  the  hand.  If  a  rent  be  made  in  the 
hand  of  the  glove,  a  fresh  glove  must  be  put  on  at  once. 
It  is,  therefore,  always  necessary  to  have  a  reserve  pair 
of  gloves,  for  the  surgeon  and  for  his  assistant,  and  several 
glove  fingers. 


Assistants  277 

At  the  first  using  of  the  gloves  the  operator  will 
doubtless  feel  that  his  fingers  are  clumsy,  and  that  it  is 
difficult  to  get  a  proper  grip  of  any  structure.  A  little 
practice,  however,  will  soon  overcome  all  these  initial 
difficulties.  If  a  flat  gauze  swab  be  used  on  the  gloved 
hand,  it  will  be  found  that  a  better  hold  is  thereby  ob- 
tained than  is  possible  with  the  bare  hand.  A  pattern 
of  glove  has  recently  been  sold  in  which  the  surface  of 
the  rubber  is  roughened  by  the  impress  of  innumerable 
fine  pits.  In  use,  however,  I  have  not  found  any  ad- 
vantage from  this. 

Assistants. — The  remarks  made  as  to  the  preparation 
of  the  surgeon  apply  also  to  his  assistant.  As  a  rule, 
only  one  assistant  is  necessary  or  desirable.  Indeed, 
many  operations,  such,  for  example,  as  gastro-enteros- 
tomy,  can  be  done  without  any  assistance.  A  good, 
well-trained  assistant  is,  however,  a  great  help.  More 
assistants  than  one  are  rarely,  if  ever,  necessary,  and  each 
one  is  an  additional  potential  source  of  infection.  The 
fewer  persons  engaged  in  an  operation  the  fewer  are 
the  chances  of  infection.  The  nurse  or  nurses  im- 
mediately engaged  in  the  operation  are  instructed  to 
prepare  in  the  same  manner  as  the  surgeon.  A  white 
sterilised  dress  or  overall  is  worn,  the  hair  is  covered 
with  a  sterile  cap,  and  clean  white  rubber  shoes  are 
worn.  If  a  nurse  helps  in  the  operation  b}^  handing 
swabs  or  sponges,  or  by  cutting  ligatures,  threading 
needles,  or  the  like,  she  should  prepare  her  hands  as 
does  the  surgeon  and  should  wear  rubber  gloves.  In 
these  circumstances  she  becomes  an  additional  assistant, 
and  if  the  same  nurse  be  employed  over  a  series  of  months 


278  Preparation   for  Operations 

or  years,  she  will  soon  become  expert  in  her  work,  and 
scrupulous  in  the  preparation  for  it. 

Swabs. — Swabs  are  employed  for  all  operations.  I 
have  ceased  to  use  marine  sponges  for  several  years; 
they  are  more  difficult  and  more  tedious  to  prepare, 
and  are  not  so  trustworthy.  The  large  flat  sponge 
certainly  answered  its  purpose,  the  protection  and  cover- 
ing of  the  viscera,  rather  better  than  any  flat  swab  I 
have  used,  but  the  difterence  is  only  slight  and  is  more 
than  compensated,  in  my  opinion,  by  the  greater  sense 
of  security  that  one  has  in  regard  to  the  sterility  of  a 
gauze  swab. 

Swabs  are  made  entirely  of  gauze  or  butter  muslin. 
I  prefer  the  latter.  The  swabs  are  of  various  sizes  from 
three  inches  square  to  six  inches  square,  and  are  made 
by  folding  over  two  or  three  times  a  large  square  of 
gauze.  The  frayed  ends  of  the  gauze  are  tucked  in, 
so  that  no  loose  filaments  are  left  on  the  wound  when 
the  swab  is  used. 

The  large  flat  swabs  are  made  of  several  layers  of 
muslin,  and  are  quilted  at  the  edge  in  order  to  prevent 
fraying.  At  the  corner  of  each  a  piece  of  tape  eighteen 
inches  in  length  is  stitched.  This  ensures  that  no  swab 
is  left  in  the  abdomen.  The  whole  of  the  gauze  square 
can  be  introduced  and  the  tape  left  hanging  from  the 
wound,  a  clip  being  fastened  on  the  end.  This  method 
is  the  most  satisfactory  of  all,  for  if  no  tape  be  aflixed, 
the  sponge  or  swab  must  be  kept  in  sight,  or  a  portion 
of  it  must  project  from  the  wound,  and  the  space  in 
which  the  surgeon  has  to  work  is  thereby  greatly  nar- 
rowed. 


Swabs  279 

The  small  swabs  are  put  up,  for  sterilising  purposes, 
in  packages  of  two  dozen,  the  large  ones  in  packages  of 
half  a  dozen.  The  number  of  each  size  used  is  counted 
at  the  completion  of  the  operation  so  as  to  make  certain 
that  none  has  been  left  in  the  abdomen.  My  own  rule 
is  never  under  any  circumstances  or  in  any  operation 
to  allow  a  small  swab  to  be  left  even  for  a  moment  in 
the  cavity — a  small  swab  is  not  allowed  to  leave  the 
hand  of  the  surgeon  or  his  assistant;  the  large  sw^abs 
are  introduced  in  any  number,  but  a  clip  is  at  once  ap- 
plied to  each  tape,  or  to  a  group  of  two,  three,  or  more 
tapes.  The  counting  of  the  swabs  under  these  conditions 
is  not  necessary,  but  it  is  as  well  to  observe  the  ceremony, 
as  it  impresses  upon  all  concerned  the  importance  of 
being  exact  in  such  matters. 

The  swabs,  after  being  made  in  the  manner  described, 
are  packed  in  a  hold-all  made  of  gamgee  tissue,  protected 
on  the  outer  side  by  brown  holland.  The  number  in 
each  package  is  always  the  same — tw^o  dozen  of  the 
smaller  sizes,  half  a  dozen  of  the  larger  size.  In  these 
packages  the  swabs  are  sterilised,  three  or  four  of  the 
hold-alls  being  wrapped  together  in  a  strong  large  towel. 
The  sterilisation  is  effected  in  a  pressure  steriliser,  a 
temperature  of  250°  C.  being  maintained  for  forty  to 
sixty  minutes. 

It  is  important  that  as  short  an  interval  as  possible 
should  elapse  between  the  sterilisation  and  the  usage 
of  the  swabs.  The  most  desirable,  though  not  always 
the  most  convenient,  arrangement  is  for  the  process 
of  sterilisation  to  conclude  within  an  hour  of  the  opera- 
tion, and  for  the  packages  to  be  taken  from  the  steriliser 


2  8o  Preparation  for  Operations 

forthwith  to  the  operation  room.  But  if  this  cannot  be 
done,  it  is  most  desirable  that  the  interval  should  not 
be  more  than  one  or,  at  the  most,  two  days.  After  a 
longer  period  than  this  it  is  desirable  to  repeat  the 
sterilisation.  The  same  rules  and  procedure  apply  to 
the  towels  used  during  the  operation.  There  should 
be  an  abundance  of  these,  used  to  cover  in  the  patient 
completely.  These  should  be  sterile,  and  their  sterilisa- 
tion should  have  been  recently  completed. 

Instruments  and  Ligatures. — Everything  used  by  the 
surgeon  or  by  the  nurses  engaged  in  the  operation  should 
be  sterilised.  Bowls,  ligature,  and  instrument  dishes, 
jugs  for  saline  solution,  and  similar  articles  should  all 
be  boiled.  These  are  often  large  and  even  cumbersome 
in  size  and  their  sterilisation  by  boiling  is  not  easily 
effected.  I  have  a  large  copper  vat,  measuring  two  feet 
by  two  feet  by  two  feet,  into  which  all  bowls  necessary 
for  any  operation  are  placed  and  therein  boiled  for 
thirty  to  forty  minutes.  If  the  operation  should  prove 
to  be  a  septic  one,  as  in  appendix  or  tubal  or  gall- 
bladder operations,  especial  care  is  subsequently  taken 
that  all  bowls,  etc.,  are  subjected  to  prolonged  boiling. 
The  washing  out  of  such  basins  with  strong  antiseptic  so- 
lutions may  be  soothing  to  the  conscience  of  the  surgeon 
or  of  the  nurse,  but  it  probably  does  not  much  affect  the 
power  of  procreation  of  a  pyogenic  organism.  Prolonged 
boiling  is  necessary. 

Catgut. — For  some  years  now  I  have  used  catgut  pre- 
pared by  a  method  I  described  in  the  Lancet  (vol.  2,  1902, 
p.  i486).     I  have  found  the  method  most  satisfactory,  and 


Instruments  and  Ligatures  281 

I  have  long  ceased  to  have  any  anxiety  whatever  about 
the  steriHty  of  the  catgut  in  any  operation. 
The  following  is  the  process: 

For  the  boiling,  an  enamelled  pan  is  used.  In  this 
about  one  and  a  half  pints  of  water  are  boiled.  While 
the  water  boils  ammonium  sulphate  is  gradually  thrown 
into  the  water.  To  obtain  a  concentrated  solution  about 
a  pound  of  ammonium  sulphate  is  used.  When  this 
concentrated  solution  boils,  the  catgut  is  introduced  and 
allowed  to  remain  for  fifteen  minutes.  With  sterile 
forceps  the  reels  are  then  lifted  out,  washed  thoroughly 
in  boiled  or  boiling  water,  and  placed  in  the  following 
solution:  iodoform,  one  part;  ether,  six  parts,  and  ab- 
solute alcohol,  fourteen  parts.  The  catgut  improves 
with  keeping  up  to  about  six  or  eight  weeks.  The 
solution  of  ammonium  sulphate  boils  at  128°  C.  The 
catgut  may  be  kept  in  it  for  an  hour  without  being 
softened,  but  fifteen  or  twenty  minutes  at  a  temperature 
of  128°  C.  are  sufficient  to  insure  sterility.  The  rinsing 
of  the  catgut  in  boiled  water  is  necessary  to  remove  the 
excess  of  salt,  which  otherwise  crystallises  on  the  catgut 
and  on  the  glass.  The  solution,  splashes  a  little  while 
boiling.  If  the  xylol  process  of  preparing  catgut  is 
used,  the  metal  receiver  may  be  boiled  in  this  solution 
instead  of  in  water,  and  the  temperature  of  the  xylol 
thus  raised  well  above  100°  C. 

Recently  I  have  used  catgut  prepared  by  the  method 
of  Claudius.  The  preparation  is  simple,  the  catgut  is 
easy  to  handle,  and  its  sterility  is  absolute. 

Catgut  is  used  for  almost  all  ligatures.  If  anything 
stronger  is  needed,  then  Pagenstecher's  celluloid  thread  is 
used.     This  is  made  in  several  sizes,  but  the  thin  and  a 


282  Preparation  for  Operations 

medium  size  are  all  that  are  necessary.  I  use  this 
material  for  all  sutures  that  are  required  to  be  long- 
enduring,  and  for  all  sutures  that  require  to  be  retained 
in  place  for  more  than  a  few  days.  The  use  of  silk  has 
been  entireh"  abandoned  by  me  for  some  years,  as  I  find 
that  the  celluloid  thread  is  more  easily  sterilised,  that  it 
presents  a  smoother  surface,  and  that  it  is  far  stronger 
than  an  equal  size  of  silk.  The  breaking  of  a  Pagen- 
stecher  thread  ligatirre  or  suture  is  an  extremely  rare 
occurrence ;  when  it  happens,  it  is  almost  certainly  due 
to  the  fact  that  the  thread  has  been  boiled  too  often. 
The  thread  when  wound  on  glass  reels  can  be  boiled 
for  four  or  five  operations,  but  after  this  it  begins  to  fray 
and  is  then  liable  to  break.  It  is.  moreover,  then  most  un- 
suitable for  sutures,  for  the  rough  surface  tears  the  peri- 
toneum as  it  is  being  pulled  through.  This  is  the  only 
fault  that  the  thread  has,  and  as  the  thread  is  verv  cheap, 
it  is  better  to  throw  it  away  after  being  boiled  three  or 
four  times  than  to  run  any  risk  of  its  breaking. 

Drainage  Material. — During  recent  years  a  marked 
change  has  come  over  surgical  opinion  with  regard  to  the 
question  of  drainage  after  abdominal  section.  At  one 
time  it  was  considered  that  drainage  was  the  safeguard 
after  all  operations ;  that  the  provision  for  the  free  escape 
of  inflammator}'  products  made  up  for  any  slight  fault 
in  the  operative  technique.  Xow,  thanks  largely  to  the 
work  of  Clark  and  others  who  have  studied  the  question 
with  great  care,  we  know  that  when  employed  as  a  routine 
measure  drainage  is  rather  a  means  of  sepsis  than  a  meas- 
ure of  escape  from  its  effects.  Drainage  of  the  peritoneal 
cavity  is  \'ery  rarely  necessary.     The  point  will  be  dealt 


Instruments  and  Ligatures  283 

with  again  when  we  come  to  speak  of  the  various  opera- 
tions ;  but,  speaking  generally,  one  may  say  that  it  is  only 
for  septic  conditions  that  drainage  is  ever  needed. 

The  best  drain  in  the  majority  of  cases  is  gauze.  It 
absorbs  well  and  conducts  fluids  away  better  than  any 
other  material.  Its  only  disadvantages  are  that  after 
remaining  in  the  abdomen  for  a  few^  days  it  is  prone  to 
become  offensive,  and  its  removal  is  difficult.  In  order 
to  overcome  the  latter  difficulty  the  gauze  may  be  sur- 
rounded by  a  rubber  tube  or  by  dental  rubber.  The  two 
forms  of  drain  which  prove  most  satisfactory  in  general 
use  are  (i)  the  split  rubber  tube  with  gauze  wick,  and  (2) 
the  so-called  "cigarette  drain." 

The  split  rubber  tube  may  be  of  any  size;  as  a  rule,  the 
larger  the  tube,  up  to  a  diameter  of  seven-eighths  of  an 
inch,  the  better.  The  tube  is  cut  of  adequate  length,  and 
a  slit  is  made  along  it  with  scissors ;  in  it  a  wick  of  gauze  is 
then  laid,  to  fit  loosely  in  the  lumen  of  the  tube  and  to  pro- 
ject for  a  couple  of  inches  from  each  end.  The  gauze  wick 
at  one  end  of  the  tube  is  then  carefully  laid  in  position 
within  the  abdomen,  and  if  necessary  either  the  gauze  or 
the  end  of  the  tube  may  be  fixed  in  position  by  a  single 
catgut  suture.  This  is  especially  necessary  w^hen  the 
drain  is  needed  at  the  upper  part  of  the  abdomen,  as, 
for  example,  after  cholecystectomy.  The  movements  of 
the  diaphragm,  and  the  consequent  up-and-down  move- 
ments of  the  liver,  are  apt  to  displace  the  gauze  or  to  roll 
it  up  into  a  ball  which  blocks  the  end  of  the  tube.  If 
fixed  with  a  stitch,  this  will  not  occur ;  the  stitch  being  of 
catgut,  softens  within  five  to  eight  days  and  the  tube  can 
then  be  removed.     The   cigarette  drain  is  made  in  the 


284  Preparation  for  Operations 

following  manner:  A  piece  of  dental  rubber,  well  boiled, 
is  cut,  about  ten  inches  square.  Over  this  a  four-fold 
layer  of  gauze  of  the  same  size  is  placed.  The  edge  of  the 
two  squares  is  then  turned  over  about  one-fourth  of  an 
inch,  and  again  over,  and  then  rolled  onwards  until  a 
cylinder  of  gauze  and  rubber  is  formed.  A  section  of  this 
C3dinder  shews  a  series  of  la^^ers,  alternately  gauze  and 
rubber,  lying  one  within  another.  It  is  as  though  there 
were  a  series  of  rubber  tubes,  of  gradually  lessening  size, 
each  with  its  own  wick  of  gauze,  one  within  another.  The 
terminal  edge  of  the  roll  may  be  fixed  with  a  stitch  or  with 
chloroform,  a  little  gauze  being  turned  in  §0  that  the  edge 
of  the  outer  rubber  can  be  opposed  to  the  underlying 
rubber  and  there  fastened.  This  drain  may  also  con- 
veniently be  fixed  in  any  desired  position  with  a  suture 
of  catgut.  In  cases  of  subphrenic  abscess  or  of  localised 
perforation  of  the  gall-bladder  where  the  cavity  to  be 
drained  is  often  extremely  foul,  the  cigarette  drain  may  be 
made  slightly  antiseptic  by  dusting  a  thick  layer  of 
powdered  boracic  acid,  with  or  without  a  little  iodoform, 
over  the  gauze  before  the  rolling-up  is  begun.  Such  a 
drain  is  best  made  at  the  moment  it  is  needed.  The 
ordinary  form  can  be  made  some  time  before  the  opera- 
tion, and  sterilised  just  before  usage.  As  a  rule,  however, 
I  make  the  drain  when  I  find  that  I  want  it,  the  materials 
for  it  being  always  ready  to  hand. 


PREPARATION  OF  THE  PATIENT. 

In  all  cases  an  adequate  preparation  of  the  patient  is 
most  necessarv.     There  are  certain  surgical  emergencies. 


Preparation  of   the  Patient  285 

catastrophes  Hke  the  perforation  of  a  gastric  or  a  duodenal 
ulcer  or  the  rupture  of  a  tubal  gestation,  in  which  the 
urgency  of  affairs  does  not  permit  any  elaborate  detail 
to  be  observed.  But  whenever  time  and  circumstance 
and  opportunity  render  it  possible,  the  preparation  of  the 
patient,  both  locally  and  generally,  should  be  most  scrupu- 
lously observed.  It  is  said  by  some  surgeons  that  strict 
preparations  are  absurd,  but  there  can  be  no  question 
that  they  repay  one  in  better  results.  The  patient  should 
be  kept  in  bed  for  the  whole  of  the  day  preceding 
operation,  and  for  the  afternoon  and  evening  of  the 
day  before  that.  If  the  operation  is  to  be  done  on 
say  Wednesday  morning,  the  patient  goes  to  bed  on 
]\Ionday  afternoon.  He  is  at  once  given  five  grains  of 
calomel,  which  is  followed  early  on  the  Tuesday  morning 
by  a  full  dose  of  saline  aperient.  Later  in  the  morning, 
if  these  have  not  acted,  an  enema  of  soap  and  water  is 
given,  and  if  the  bowels  are  at  all  loaded  or  the  patient 
has  previously  suffered  from  constipation,  the  enema  is 
repeated  late  at  night.  The  condition  of  the  mouth 
receives  close  attention.  Every  patient  is  given  a  new 
tooth-brush  and  a  bottle  of  antiseptic  mouth- wash  on 
arrival  in  the  nursing  home  or  hospital,  and  the  nurse  is 
instructed  to  see  that  a  thorough  cleansing  of  the  mouth 
is  observed  every  hour  or  two  during  the  day.  It  is 
astonishing  to  what  a  degree  of  uncleanness  even  the 
better  class  of  people  will  allow  their  teeth  to  go.  Patients 
with  gastric  ulcer  and  its  complications  seem  to  suffer 
especially  from  bad  teeth,  and,  indeed,  the  point  is  worth 
raising  as  to  the  degree  in  which  oral  sepsis  may  be  a 
factor  in  the  causation  of  gastric  ulcer.    If  the  patient  is  in 


286  Preparation  for  Operations 

very  feeble  health,  the  nurse  is  instructed  to  clean  the 
patient's  mouth  by  frequent  wiping  with  gauze  or  lint, 
and  the  patient  subsequently  rinses  the  mouth  out.  It 
is  possible,  as  the  excellent  work  of  Dr.  Harvey  Gushing 
has  shewn,  by  careful  attention  to  the  condition  of  the 
mouth  and  by  the  sterilisation  of  all  foods,  to  render  the 
alimentary  canal  comparatively  aseptic.  All  patients 
from  the  moment  they  are  received  into  hospital  are  fed 
on  fluid  diet,  and  everything  given  is  sterilised,  and  the 
feeder  or  vessel  from  which  the  food  is  taken  is  also  boiled. 

I  am  disposed  to  think  that  the  occurrence  of  parotitis 
and  of  pneumonia  after  abdominal  operations  are  both 
largely,  if  not  solely,  due  to  infection  from  the  mouth. 
In  some  cases  so  foul  a  condition  of  teeth  and  gums  may 
be  accidentally  discovered  as  to  make  a  little  delay  in 
operating  imperative.  In  one  patient  I  found  quite 
by  accident  a  degree  of  suppuration  in  the  mouth  and  a 
foetor  of  breath  that  warranted  a  diagnosis  of  Riggs's 
disease.  In  such  a  case,  and  even  in  bad  cases  of  carious 
teeth,  an  aspiration  pneumonia  is  not  unlikely  to  occur,  or 
an  extension  of  inflammation  up  Stenson's  duct,  unless 
a  thorough  and  repeated  cleansing  is  observed. 

The  skin  of  the  abdomen  needs,  and  must  receive,  very 
careful  preparation.  The  hair  is  first  shaved  awc'w  from 
the  whole  abdominal  wall  and  from  the  pubes.  It  is 
evidence  of  careless  work  to  see  a  patch  only  shaved,  one 
half  of  the  pubic  hair,  for  instance,  remaining  untouched. 
It  is  well  to  limit  the  operative  field,  of  course,  but  the 
preparation  of  the  skin  must  extend  wide  beyond  it. 

A  free  washing  with  soap  and  hot  water  frequently 
changed  is  first  necessary.     The  best  material  wherewith 


Preparation  of  the  Patient  287 

to  wash  is  sterile  gauze  in  large,  pads.  These  are  moist- 
ened with  hot  water  and  rubbed  w4th  soap  till  a  good 
lather  is  obtained.  This  washing  should  be  continued  for 
a  quarter  of  an  hour,  the  water  and  the  gauze  being  fre- 
quently changed.  An  antiseptic  compress  is  then  applied 
and  left  on  for  twenty  to  twenty-four  hours,  or  until  the 
movements  of  the  patient  begin  to  displace  it.  The 
compress  consists  of  lint  of  two  or  three  thicknesses, 
soaked  in  one  per  cent,  formalin,  i  in  60  carbolic,  or  i  in 
2000  biniodide  lotion.  I  prefer  the  former,  in  the  belief 
that  there  is  by  its  means  a  deeper  penetration  of  the 
skin  and  of  the  glands. 

At  the  end  of  twenty-four  hours  there  is  a  second 
washing,  and  a  second  similar  compress  is  applied.  This 
is  removed  immediately  before  the  operation,  when  a  third 
cleansing  is  made.  The  skin  is  now  rubbed  with  spiritus 
saponatus — a  solution  of  soap  in  spirit — a  swab  wet  with 
1 :  1000  biniodide  solution  being  used  to  make  a  fine  lather. 
This  is  wiped  away  with  biniodide  lotion  and  finally  the 
skin  is  wiped  over  with  sterile  salt  solution. 

Some  patients'  skins  are  very  tender  and  will  not  bear 
this  preparation.  If  not,  the  second  washing  is  omitted, 
for  it  is  supremely  important  that  the  skin  should  not  be 
roughened  or  chapped,  and  that  any  irritative  rash  should 
not  be  caused.  Overpreparation  to  the  extent  of  damag- 
ing the  skin  is  almost  as  bad  as  no  preparation  at  all. 
If  there  are  any  small  furuncles  or  septic  cracks  on  the 
skin  within  the  operation  area,  these  must  be  carefully 
disinfected.  The  only  satisfactory  method  of  doing  so  is 
by  means  of  the  actual  cautery,  the  point  of  the  hot  metal 
being  kept  in  contact  with  the  infected  spot  until  all  the 


288  Preparation  for  Operations 

septic  matter  is  destroyed.  When  it  is  realised  that  the 
yellow  spot  in  a  furuncle  may  contain  a  pure  culture  of  the 
staphylococcus  pyogenes  aureus,  the  complete  annihila- 
tion of  such  a  colony  is  seen  to  be  a  desirable  thing. 

If  the  skin  of  the  patient  should  be  very  rough,  scaly, 
chapped,  or  cracked,  its  adequate  preparation  is  almost 
impossible.  In  these  conditions  the  "rubber  dam" 
introduced  by  Dr.  J.  B.  Murphy  of  Chicago  will  be  found 
of  the  greatest  service.  It  consists  of  a  strong,  very 
adhesive  material,  which  is  stretched  and  then  placed  on 
the  abdominal  wall,  to  which  it  clings  most  closely,  be- 
coming, in  fact,  for  the  time,  an  inseparable  part  of  this 
wall. 

Through  it  the  incision  is  made,  and  the  hand  lying 
outside,  or  any  viscus  escaping  from  the  abdomen,  lies 
not  upon  the  abdominal  wall,  but  upon  this  sterile  rubber 
dam. 

i\s  a  general  rule,  no  more  preparations  than  those 
indicated  are  necessary,  but  in  some  few  the  general  con- 
dition of  the  patient  may  be  so  enfeebled  that  special 
precautions  are  needed.  It  is  a  matter  of  the  highest 
importance  in  all  cases  to  ensure  that  the  heart  and  the 
kidneys  are  acting  well.  Inefficient  kidneys  are  among 
the  most  serious  obstacles  to  success  in  any  major  opera- 
tions, but  especially  in  any  abdominal  operations.  A 
routine  and  most  exact  examination  of  the  urine  for  two 
or  three  days  is,  therefore,  necessary.  If  the  patient  be 
feeble,  or  the  heart  so  weak  as  to  be  a  cause  of  anxiety, 
much  good  may  be  done  by  hypodermic  injections  of 
strychnine  and  digitaline  for  a  few  days  before  the  opera- 
tion.    Five   minims   of  the   liquor   strychninse  may  be 


Operation  289 

given  three  or  four  times  daily.  If  the  patient  has  been 
accustomed  to  alcohol,  his  usual  quantity  may  be  al- 
lowed him.  All  patients  who  are  submitted  to  any 
abdominal  operations  are  clothed  in  a  suit  of  gamgee 
pajamas  made  for  them  by  the  nurse.  After  being  made, 
of  appropriate  size,  the  suit  is  well  warmed  and  is  put  on  a 
few  hours  before  the  beginning  of  the  operation.  It  is 
worn  until  all  risk  from  the  operation  is  past,  and  is  then 
removed  limb  by  limb. 


OPERATION. 

The  operation,  if  possible,  should  be  performed  in  a. 
room  specially  furnished  for  the  purpose.  In  a  public 
hospital  a  well-equipped  operation  theatre  is  always 
provided.  In  a  nursing  home  or  in  a  private  house  it  is 
sometimes  necessary  to  operate  in  the  patient's  bed- 
room. The  advantage  of  this  is  that  it  is  less  of  an  ordeal 
to  the  patient,  who  is  sometimes  alarmed  at  the  prospect 
of  being  taken  to  a  special  room,  and  that  there  is  less 
of  lifting  or  of  carrying  after  the  operation.  These 
trivial  advantages  are,  however,  greatly  outweighed  b}^ 
the  disadvantages,  which  are,  that  in  the  conversion  of  a 
bedroom  into  a  theatre  there  is  much  traffic,  many 
tables,  instruments,  etc.,  having  to  be  taken  into  the 
room;  that  it  is  not  possible  to  have  all  the  needed  ap- 
pliances to  hand  with  the  same  certainty,  and  that  finally 
the  smell  of  the  auEesthetic  clings  to  the  room  for  many 
hours.  An  ordinary  room  in  a  nursing  home  can  readily 
be  converted  into,  and  equipped  as,  an  operation  room, 
to  the  great  convenience  of  the  surgeon.  The  operation 
19 


290  Preparation  for  Operations 

table  should  have  the  foot  towards  the  light,  and  should  be 
of  good  height.  Many  of  the  tables  are  about  three  inches 
too  low.  If  the  table  is  high,  it  is  more  convenient  and 
more  comfortable  for  the  surgeon,  and  if,  for  any  brief 
manipulation,  it  is  necessarv^  for  the  surgeon  to  be  at  a 
rather  high  level,  a  plain  metal  or  wooden  footstool  can  be 
used. 

AFTER-TREATMENT. 

No  small  portion  of  the  success  in  all  abdominal  opera- 
tions depends  upon  the  after-treatment.  When  the 
patient  is  returned  to  bed,  she  is  generally  propped  up 
slightly,  by  three,  four,  or  five  pillows.  If  a  drainage-tube 
is  left  in  the  wound,  its  outer  end  is  fitted  into  a  bottle  of 
about  ten  ounces  capacity,  which  is  fixed  by  a  safety  pin 
to  the  side  of  the  dressing.  During  the  first  few  hours 
bile  may  flow  in  ^•ery  small  quantity,  especially  in  cases 
where  the  action  of  the  hepatic  cells  has  been  in  part  sup- 
pressed by  the  tension  and  sepsis  in  the  common  and 
hepatic  ducts,  as  a  result  of  the  occlusion  of  the  duct 
by  a  stone.  The  bile  that  first  flows  may  be  muddy  or 
turbid,  but  after  a  few  days  the  bile  flows  in  greater  quan- 
titv  and  it  becomes  gradually  clearer.  The  patient  is 
allowed  no  sip  of  water  until  the  ether  sickness  and  the 
feeling  of  nausea  are  over.  In  all  cases  the  abdominal 
bandage  is  applied  tightly,  so  that  if  vomiting  should 
occur,  the  wound  may  thereby  receive  some  support.  If 
thirst  is  great,  the  mouth  may  be  flushed  frequently  with 
w^ater  or  soda  water,  and  an  enema  of  salt  solution,  from 
ten  ounces  to  twenty  ounces  in  quantity,  may  be  given. 
If  the  pain  is  severe,  ten  grains  of  aspirin  may  be  given 


After-treatment  291 

by  the  mouth,  or  twenty  grains  by  the  rectum.  Morphia 
is  never  given  during  the  first  twenty-four  hours  and 
very  rarely,  indeed,  afterwards.  In  some  cases,  espe- 
cially in  old  and  enfeebled  patients  who  have  slept  but 
little  or  not  at  all  during  the  first  night,  and  who  do 
not  seem  likely  to  sleep  during  the  second  night,  a 
small  dose  of  morphia,  one-sixth  of  a  grain  for  exam- 
ple, may  safely  be  given  if  the  patient  is  otherwise 
in  a  satisfactory  condition.  On  the  third  or  on  the 
fourth  night  it  may  be  given  under  like  circumstances. 
A  good  night's  rest  often  is  a  great  help  to  a  patient 
who  is  enfeebled  by  a  long-enduring  disease  and  dis- 
tressed by  the  anxiety  of  a  serious  operation.  Under 
these  rare  circumstances,  therefore,  morphia  may  be 
given,  but  it  must  not  be  repeated. 

Saline  injections,  about  six  ounces  every  four  hours,  are 
given  for  the  first  two  or  three  days.  If  the  pulse  is 
poor  or  the  patient  at  all  collapsed,  an  occasional  hypo- 
dermic of  five  or  ten  minims  of  liquor  strychninas  is 
given. 

As  soon  as  the  sickness  is  over  a  few  teaspoonfuls  of 
fluid  are  given  by  the  mouth.  Water,  or  tea  made  to  the 
patient's  liking,  is  the  best;  on  the  second  day  milk  and 
soups  may  be  given;  on  the  third  the  same,  with  milk 
puddings  and  a  little  bread  and  butter. 

The  condition  of  the  mouth  receives  constant  attention. 
The  teeth  are  cleansed  three  or  four  times  a  day  by  the 
patient  or  by  the  nurse,  and  a  wash  of  some  weak  and 
fragrant  antiseptic  is  frequently  employed. 

Drainage-tubes  are  left  in  until  the  stitch  which  fixes 
them    loosens    spontaneously-.     This    occurs    about    the 


292 


Preparation  for  Operations 


seventh  to  the  tenth  day.  The  tube  is  removed  and  the 
wound  is  then  dressed  daily.  While  the  tube  is  still  in  the 
wound  it  is  not  necessary  to  change  the  dressings  unless 
they  are  soiled  by  leakage  of  bile  by  the  side  of  the 
tube.  If  gauze  packing  is  employed,  it  may  be  left 
from  four  to  eight  days.  The  stitches  are  removed 
about  the  eighth  day. 

If  the  patient  is  old  and  feeble,  she  is  allowed  to  sit 
up  out  of  bed  within  three  or  four  days.  In  all  such  cases 
through  and  through  stitches  will  have  been  employed, 
and  there  is  consequently  little  or  no  risk  of  damage  to 
the  wound. 


CHAPTER  X. 

OPERATIONS   UPON    THE   GALL-BLADDER   AND 
BILE-DUCTS. 

HISTORICAL. 

The  history  of  the  surgery  of  the  bile  passages  is  full 
of  interest.  Langenbuch,  in  a  paper  read  before  the  Ger- 
man Congress  of  Surgeons  in  1896,  has  given  a  detailed 
account  of  the  various  steps  by  which  the  treatment  by 
surgical  methods  of  cholelithiasis  and  of  its  many  com- 
plications has  been  laboriously  built  up ;  and  in  the  follow- 
ing account  I  have  borrowed  freely  from  his  paper. 

The  first  record  of  the  removal  of  a  gall-stone  from  a  liv- 
ing patient  is  found  in  the  year  16 18,  the  operator  being 
Fabricius  Hildanus.  In  1630  Zambeccari,  an  Italian, 
performed  cholecystectomy  upon  a  dog.  The  animal 
recovered,  and  two  months  later  was  killed.  At  the 
examination  it  was  found  that  the  omentum  and  bowels 
were  adherent  over  the  stump  of  the  cystic  duct.  In 
1667  a  student,  Teckof,  in  Ley  den,  removed  the  gall- 
bladder from  several  dogs.  EttmiiUer,  referring  to  the 
work  of  Teckof,  says :  "  As  we  now  know,  the  gall-bladder 
can  be  removed  from  dogs  without  detriment  to  life  or 
health.  I  was  first  informed  briefly  of  this  by  a  friend 
who  told  me  that  a  student  of  Leipzig  had  removed  the 
gall-bladder  from  a  dog  three  months  before,  and  had 
closed  the  abdominal  wound  at  once.  This  animal  still 
lives  and  fulfils  all  the  functions  of  life  without  the  least 
disturbance." 

Further   experimental   work   was   done   by    Malpighi, 

293 


294    Operations  on   Gall-bladder  and  Bile-ducts 

Taubrin,  and  others  and  by  Seeger,  by  whom  it  was  shewn 
that  ligature  of  the  cystic  duct  gave  rise  to  hydrops  of  the 
gall-bladder. 

Gall-stones  were  removed  by  operations  performed,  in 
1687,  by  Stalpart  van  der  Wiel;  in  1738  by  Amy  and,  and 
in  1742  by  ]\Iuller.  These  operations  were  in  all  cases  the 
result  of  accident,  rather  than  deliberately  planned  and 
purposeful  operations. 

The  first  surgeon  who  carefully  devised  and  deliberately 
carried  out  an  operation  for  the  removal  of  gall-stones  was 
Jean  Louis  Petit,  in  1743.  His  procedure  was  limited  to 
those  cases  in  which  it  was  thought  that  the  gall-bladder 
was  adherent  to  the  abdominal  wall.  This  adhesion  was 
diagnosed  when  a  tumour  of  the  gall-bladder  was  present 
which  was  not  movable  from  side  to  side,  or  when  an 
inflammation  over  the  gall-bladder  seemed  on  the  point 
of  bursting  through  the  skin.  In  one  case  certainly,  the 
patient  being  a  woman,  he  operated  with  success  at 
several  sittings.  He  writes:  "How  many  people  have 
died  because  this  disease  was  not  recognised,  or  because  no 
operator  could  be  found  who  would  undertake  to  rid  them 
of  their  disease  by  means  of  an  operation ! ' ' 

Petit's  work  w^as,  however,  ignored  by  many  of  his 
contemporaries  and  successors,  though  it  was  recognised 
by  Haller,  and  operations  were  performed  by  Morand  and 
Sharp. 

Herlin,  in  1767,  performed  a  number  of  experiments 
upon  dogs  and  found,  as  Teckof  before  him  had  found, 
that  the  gall-bladder  could  be  safely  removed.  He 
advised  extirpation  of  the  gall-bladder  as  a  remedy  for 
cholelithiasis. 

The  next  advance  was  made  by  Bloch  of  Berlin  in 
1774,  who  attempted  to  create  an  artificial  adhesion  of 
the  gall-bladder  to  the  parietal  peritoneum  by  means  of 
the  application  of  irritant  materials  to  the  skin.  In 
three  cases  he  operated  successfully. 


Historical  .  295 

August  Gottlieb  Richter,  the  famous  German  surgeon, 
first  suggested  that  adhesion  of  the  gall-bladder  to  the 
parietal  peritoneum  was  not  an  essential  preliminary 
to  an  operator.  He  wrote:  "Is  then  an  escape  of  bile 
into  the  belly  cavity  to  be  feared  when  the  gall-bladder  is 
not  adherent  to  the  peritoneum  if  the  trocar  be  used,  and 
be  left  in  the  wound  after  the  gall-bladder  is  empty? 
Have  we  not  cause  to  hope  that  the  cannula  will  cause  the 
gall-bladder  to  adhere  to  the  peritoneum,  preventing 
it  from  moving  away  by  the  creation  of  adhesions?" 
As  a  step  further  than  this  may  be  mentioned  the  pro- 
cedure adopted  by  Sebastian,  Carre,  and  Fauconneau- 
Dufresne,  in  which  the  abdominal  wall  was  incised  down 
to  the  parietal  peritoneum,  and  into  the  wound  irritating 
substances  were  placed  to  promote  adhesions.  Kocher 
in  1878  opened  the  abdomen  and  packed  around  the  gall- 
bladder with  Lister's  gauze,  and  six  days  later,  when  ad- 
hesions had  formed,  he  opened  the  gall-bladder  and 
emptied  it ;  the  patient  recovered  completely. 

The  next  advance  is  due  to  Thudichum,  w^ho,  in  1859, 
suggested  that  the  operation  of  cholecystotomy  should  be 
performed  in  two  stages,  the  gall-bladder  being  stitched 
to  the  abdominal  wound  in  the  first  stage,  and  in  the 
second,  the  gall-bladder  being  opened.  The  advocacy 
of  this  method,  however,  found  no  favour,  and  for  eight 
years  there  is  no  record  of  any  operations  having  been 
performed  upon  the  gall-bladder  or  the  bile  passages. 

In  the  year  1867  Bobbs,  an  American  surgeon,  per- 
formed cholecystotomy  in  one  stage.  After  opening  the 
abdomen  the  gall-bladder  was  brought  up  into  the  ab- 
dominal wound,  opened  and  emptied,  and  then  sutured 
to  the  parietal  peritoneum.  The  operation  was  based 
upon  an  inaccurate  diagnosis ;  it  was  thought  that  a  large 
fluctuating  tumour  was  an  ovarian  cyst ;  on  exploration 
it  proved  to  be  a  dropsical  gall-bladder.  This  opera- 
tion attracted  so  little  contemporary  notice  that  several 


296    Operations  on   Gall-bladder  and   Bile-ducts 

operators,  Daly  (Lancet,  1876),  Maunders  (Brit.  Med. 
Journ.,  1876),  Handfield  Jones  (Med.  Times  and  Gazette, 
1878),  Brown  (Brit.  Med.  Journ.,  1878)  all  believed  that 
their  methods  were  original.  In  1877  Marion  Sims  and 
Keen  performed  cholecystotomy  after  the  method  em- 
ployed by  Bobbs.  Marion  Sims'  patient  suffered  from 
calculous  obstruction  of  the  common  duct,  and  died  of 
haemorrhage.  The  credit  of  performing  the  first  in- 
tentional and  successful  cholecystotomy,  in  two  stages, 
belongs  to  Konig,  who  operated  in  1882.  The  year  1882 
was  the  most  memorable  of  all  in  the  development  of  gall- 
bladder surgery,  for  it  was  in  this  year  that  Langenbuch 
first  performed  the  operation  of  cholecystectomy.  To 
Langenbuch,  as  much  as  to  any  surgeon,  belongs  the 
credit  of  establishing  the  surgery  of  the  gall-bladder  upon 
a  firm  footing.  His  operative  work  is  the  work  of  a 
pioneer,  and  his  book  upon  the  diseases  of  the  liver 
and  the  gall-bladder  is  probably  the  soundest  and  most 
authoritative  treatise  we  possess.  Langenbuch,  on  July 
15,  1882,  after  long  practice  of  the  operation  upon  the 
cadaver,  performed  cholecystectomy  upon  one  of  his 
patients,  and  a  speedy  and  successful  result  followed. 
Other  similar  operations  were  performed  by  Langenbuch 
himself,  by  Courvoisier,  and  by  Riedel. 

The  year  1882  saw  the  first  performance  of  another 
operation  upon  the  bile  passages,  the  operation  of  chole- 
cystenterostomy,  which  was  carried  out  in  six  stages  by 
von  Winiwarter.  The  suggestion  of  the  operation  is 
due  to  Nussbaum.  \^on  Winiwarter  united  the  gall- 
bladder to  the  colon.  Cozi,  after  many  experiments 
upon  dogs,  suggested  that  the  anastomosis  should  be 
made  with  the  duodenum.  This  was  done  by  Barden- 
heuer  and  Terrier.  In  1885  Roth,  a  Swiss  surgeon, 
suggested  that  in  blockage  of  the  common  duct  the 
cystic  duct  might  be  implanted  in  the  duodenum. 

The  year  1884  saw  the  first  attempts  in  surgical  inter- 


Historical  297 

ference  with  the  common  duct.  The  operations  of 
choledochotomy  and  of  duodeno-choledochotomy  were 
both  suggested  by  Langenbuch,  and  the  possibiHty  of 
their  performance  demonstrated  by  experiments  upon 
the  cadaver.  Duodeno-choledochotomy  was  first  per- 
formed by  MacBurney,  then  by  Pozzi  and  Kocher. 
Choledocho-duodenostomy  was  first  performed  by  Riedel 
unsuccessfully,  by  Sprengel  successfully. 

The  first  surgeon  to  attempt  choledochotomy  was 
Klimmel;  the  result  was  unsuccessful.  Courvoisier  per- 
formed the  first  successful  operation.  In  1891  Hochen- 
egg,  after  removing  a  stone  from  the  common  bile-duct, 
did  not  introduce  sutures,  but  drained  the  wound  with 
gauze;  his  patient  recovered.  The  operation  of  chole- 
docholithotripsy  was  performed  by  Langenbuch,  Cour- 
voisier, Lawson  Tait,  and  others.  Rehn  was  the  first 
surgeon  to  perform  cholecystectomy  and  choledochotomy 
successfully. 

In  the  year  1884  Kiister  performed  the  first  operation 
for  acute  ulcerative  perforation  of  the  gall-bladder.  The 
first  hepatotomy  was  performed  by  Korte. 

In  the  year  1883  Sir  Spencer  Wells  recommended  the 
operation  of  ideal  cholecystotomy,  or  cholecystendysis. 
Two  unsuccessful  results  were  recorded  by  Meredith,  and 
were  followed  by  a  successful  operation  performed  by 
Courvoisier. 

In  1884  Riedel  operated  successfully  for  the  relief  of 
a  fistula  of  the  gall-bladder,  communicating  with  the 
colon  and  with  the  right  pleural  cavity.  Kronlein  in 
1886  closed  a  fistulous  track  which  extended  from  the  gall- 
bladder to  the  bladder,  and  one  year  later  von  Bergmann 
evacuted  gall-stones  from  a  distended  patent  urachus 
which  communicated  with  the  gall-bladder. 

In  1886  Landerer  performed  cystolithectomy  through 
the  liver  substance,  and  Lauenstein  hepatolithectomy 
in  two  stages. 


298    Operations  on  Gall-bladder  and  Bile-ducts 

In  1890  Hochenegg  was  the  first  to  remove  a  malignant 
tumour  of  the  gall-bladder,  and  in  the  same  year  Terrier 
removed  a  growth  which  involved  the  gall-bladder  and 
the  adjacent  portion  of  the  liver. 

The  use  of  omental  flaps  and  grafts  for  walling  off 
incisions  in  the  bile  passages  was  advocated  first  by 
Courvoisier  and  by  Mayo  Robson.  The  first  operations 
for  peritoneal  adhesions  which  crippled  the  action  of  the 
gall-bladder  and  the  stomach  were  performed,  according 
to  Langenbuch,  by  Riedel  and  Lauenstein.  In  England, 
Mayo  Robson,  and  in  France,  Terrier,  both  recognised 
the  harm  done  by  adhesions  affecting  these  organs,  and 
the  great  relief  afforded  by  the  free  division  of  them. 
The  operation  of  cysticotomy  originated  with  Kiister. 

In  England,  the  first  surgeon  to  operate  deliberately 
and  with  success  for  gall-stone  diseases  was  Lawson 
Tait.  No  small  measure  of  credit  for  the  successful  per- 
formance and  advocacy  of  the  surgical  treatment  of 
diseases  aft'ecting  the  gall-bladder  and  bile-ducts  is  due 
to  two  surgeons  attached  to  the  Leeds  Infirmary,  McGill 
and  Mayo  Robson.  ]\IcGill  was  undoubtedly  one  of 
the  pioneers  in  this  branch  of  our  art,  and,  possessed  as 
he  was  of  the  very  genius  of  surgery,  he  would,  if  his 
brilliant  career  had  not  been  prematurely  cut  short,  have 
achieved  in  it  a  great  and  enduring  reputation.  What 
]\Iayo  Robson  has  done  for  the  surgery  of  the  abdomen  in 
general,  and  perhaps  especially  for  the  surgery  of  the  gall- 
bladder, is  well  known  to  all.  His  little  work,  published 
in  1892,  followed  by  his  Hunterian  lectures,  and  three 
editions  of  the  work  based  upon  them,  are  a  record  which 
we,  at  his  hospital,  are  proud  to  remember. 


General  Observations 


299 


GENERAL  OBSERVATIONS. 

In  all  operations  upon  the  gall-bladder  or  upon  the 
bile-ducts  a  considerable  advantage  will  be  derived  from 
the  use  of  a  sand-bag  placed  under  the  patient's  back  at, 
or  a  little  above,  the  level  of  the  liver.  The  liver  by  this 
means  is  made  to  present  in  the  wound  and  easy  access 


Fig.   58. — Shewing  the  position  of  the   sand-bag  in  operations  upon 
the  gall-bladder  and  bile-ducts. 


is  obtained  to  the  cystic  and  common  ducts.  The  in- 
testines fall  away  into  the  pelvis,  and  the  whole  operation 
area  is  made  more  accessible.  In  addition  to  this  use  of 
the  sand-bag  it  will  be  found  a  convenience  to  be  able 
slightly  to  tilt  the  table  so  that  the  head  of  the  patient 
is  raised  and  his  feet  lowered  about  four  to  six  inches. 

It  is  to  Wheelock  Elliot  of  Boston  that  we  are  indebted 
for  the  first  demonstration  of  the  great  advantage  to  be 


300    Operations  on   Gall-bladder  and   Bile-ducts 

derived  from  the  placing  of  the  patient  in  this  position. 
He  writes  (Annals  of  wSurgery,  1895,  vol.  22,  p.  97): 

"The  patient  is  hung  by  straps  under  the  arms  on  an 
inclined  plane  at  an  angle  of  something  less  than  forty- 
five  degrees.  A  sand-bag  is  placed  under  the  back,  so 
that  the  patient  is  bent  over  it.  In  this  position  the 
intestines  gravitate  to  the  lower  part  of  the  abdomen,  so 
that  when  the  liver  is  held  up  by  a  retractor,  the  air 
sucks  in  between  the  liver  and  intestines  much  as  it 
enters  the  pelvis  in  the  Trendelenburg  position. 

The  only  disadvantage  of  this  position  is  that,  when  a 
vertical  incision  is  employed,  the  edges  of  the  wound  are 
necessarily  very  tense,  owing  to  the  pushing  forward  of 
the  rib  margin  and  the  consequent  tightening  of  the 
abdominal  muscles.  This  solitary  disadvantage  is  done 
away  with  when  Mayo  Robson's  incision,  to  be  presently 
described,  is  used.  This  position  of  the  patient  is,  as  a 
fact,  indispensable  for  easy  work  upon  the  ducts. 

The  best  incision  is  a  vertical  one,  made  at  first  about 
four  to  five  inches  in  length  through  the  right  rectus  near 
its  outer  border.  The  upper  end  of  the  incision  starts  at 
the  costal  margin  and  extends  vertically  downwards.  If 
more  room  is  needed  than  this  incision  gives,  it  may  be 
obtained  by  prolonging  the  incision  downwards,  or  by 
carrying  the  upper  end  obliquely  upwards  and  inwards, 
dividing  the  fibres  of  the  rectus  about  one-half  of  an  inch 
from  the  costal  margin.  There  is  rarely  any  need  for  a 
further  increase  of  the  incision  than  these.  The  incision 
near  the  outer  margin  of  the  rectus,  with  the  upward  and 
inward  extension,  is  that  first  suggested  by  Mayo  Robson. 


General  Observations 


;oi 


Great  convenience  may  often  be  gained,  especially  in 
stout  patients  with  an  abdominal  wall  three  inches  or 
more  in  thickness,  by  making  the  skin  incision  two  or  three 
inches  longer  than  the  incision  in  the  rectus.  The  sides 
of  the  wound  then  fall  away  and  allow  the  more  ready 
access  of  the  hand.  The  longer  incision  in  the  skin  and 
subcutaneous  fat  does  not  in  any  way  weaken  the  ab- 
dominal wall,  as  a  longer  in- 
cision in  the  muscles  would  ,...  ,-  ■...  ,.--.:'  ,. 
certainly  do. 

Dr.  Arthur  Dean  Bevan  of 
Chicago  has  suggested  (An- 
nals of  Surgery,  vol.  30,  p.  17) 
the  use  of  an  S -shaped  inci- 
sion, the  lower  end  of  the  ver- 
tical incision  being  carried 
outwards,  and  the  upper  end 
obliquely  upwards  and  in- 
wards. Dr.  Bevan  claims  that 
by  means  of  his  incision  less 
damage  is  done  to  the  vessels 

and  nerves  of  the  abdominal  wall  than  by  other  incisions, 
and  that  a  better  view  can  be  obtained  of  the  bile-ducts. 
The  incision  of  Mayo  Robson  is  practically  the  same  as 
the  upper  part  of  Bevan 's  incision. 

Kocher  uses  an  oblique  incision  four  inches  in  length, 
about  one  and  one-half  inches  below  the  costal  margin. 
The  centre  of  the  incision  is  a  little  outside  the  outer 
margin  of  the  rectus  muscle.  This  is  a  very  useful  in- 
cision, giving  ready  access  to  the  gall-bladder  and  ducts, 
being  readily  enlarged  either  inwards  or  outwards,  and 


Fig.  59. 


Mayo   Robson's  in- 
cision. 


302    Operations  on  Gall-bladder  and  Bile-ducts 

doing  little  damage  to  the  nerves  or  muscles  of  the  ab- 
dominal wall.  Very  little  weakness  of  the  parietes 
remains  after  the  operation,  and  there  is  little  chance  of 
a  hernia  developing.  This  incision  and  the  vertical  inci- 
sion, with  Mayo  Robson's  extension,  are  the  only  ones 
I  have  adopted.  So  far  as  I  am  aware,  I  have  not  had 
a  single  case  of  post-operative  hernia.  This  I  attribute 
in  part  to  the  method  of  making  the  incision  (a  large  skin 
wound  and  a  small  muscle  wound),  but  chiefly  to  care  in 


./yv;;"-- 


FiG.  60. — Arthur  Dean  Bevan's 
incision. 


V   / 

Fig.  61. — Kocher's  incision. 


stitching  up  the  wound.  Courvoisier's  incision  is  eight 
to  ten  inches  in  length,  and  runs  almost  parallel  with  the 
costal  margin.  Kehr  makes  use  of  an  incision  even  longer 
than  this. 

Such  phenomenal  incisions  as  these  two  latter  are  never 
necessary.  With  a  vertical  incision  five  or  six  inches 
in  length,  and  at  the  most  an  oblique  upward  and  in- 
ward prolongation  of  this  just  below  the  costal  margin, 
any  operation  can  be  performed  upon  any  part  of  the  gall- 


General  Observations 


303 


bladder  or  the  cystic  or  common  or  hepatic  ducts.  Pro- 
vided the  ducts  are  brought  within  easy  reach,  then  the 
smaller  the  incision  the  better,  for  the  intestine  can  the 
more  readily  be  packed  away  with  swabs  or  sponges. 
A  long  incision  is  troublesome  in  that  it  allows,  the  escape 
of  intestines  from  the  wound  and  makes  the  retention  of 
the  bowels  within  the  abdomen  a  matter  of  constant 
attention.  As  soon  as  the  abdomen  is  opened  and  a 
preliminary  exploration  has  been  made,  a  large  flat  swab 
is  packed  down  towards  the  upper  part  of  the  right  kidney 


^i^iW^WB8Hff™w^**V»^ 


Fig.  62. — Gall-stone  scoop  (a)  and  forceps  (6). 


pouch.  The  proper  placing  of  this  swab  is  a  matter  of 
the  greatest  importance.  It  should  fill  the  upper  part  of 
the  right  kidney  pouch,  fitting  in  between  the  common 
duct  and  the  duodenum  on  the  inner  side,  and  the  ab- 
dominal wall  on  the  outer  side.  When  fixed  in  its  correct 
position,  it  forms  an  adequate  protection  against  any 
leakage  from  the  opened  bladder  or  ducts.  When  the 
operation  is  completed  and  the  swab  is  removed,  there 
should  have  been  no  soiling  of  any  part  of  the  peritoneum 
which  it  covers. 


304    Operations  on  Gall-bladder  and  Bile-ducts 

A  second  swab  of  smaller  size  is  then  passed  towards 
the  middle  line,  to  lie  above  the  stomach  to  the  inner  side 
of  the  common  duct.  The  exact  fixing  of  this  is  also 
important,  though  it  is  more  easily  placed  than  is  the 
former.  A  large  swab  is  also  placed  so  as  to  cover  the 
intestines  and  protect  them  entirely.  If,  in  very  stout 
patients,  one  swab  will  not  suffice  for  this,  two  or  more 
may  be  introduced. 

The  liver  and  the  gall-bladder  are  then  freed  from  any 
adhesions.  These  are  sometimes  thin,  loose,  and  easily 
divided;  at  other  times  they  are  exceedingly  tough, 
intricate,  and  difficult  to  separate.  The  greatest  care  and 
deliberation  must  be  exercised  in  disentangling  these. 
Any  hurry  or  any  undue  force  may  be  fatal ;  the  colon  or 
the  duodenum,  or  even  the  stomach,  may  be  torn,  and 
leakage  from  these  viscera  may  contaminate  the  whole 
field.  A  rough  separation  of  the  omentum  may  cause 
a  profuse  haemorrhage,  and  the  torn  vessel,  retracting, 
may  cause  a  large  haematoma  to  form  in  the  substance  of 
the  omentum.  In  the  stripping  of  all  these  adhesions 
great  help  will  be  found  in  the  use  of  gauze,  which  wrapped 
around  the  fingers  slowly  peels  the  adhesion  away.  It  is 
most  essential  that  all  the  ducts  and  the  gall-bladder 
should  be  freed  and  laid  bare  before  the  operation  pro- 
ceeds further. 

Unless  all  the  bile-tract  can  be  explored,  there  is  a  great 
risk  of  a  small  calculus,  or  even  of  many  calculi,  being 
left  behind.  Adhesions,  even  the  very  firmest,  will 
yield  to  time  and  patience  and  dexterity.  No  operation 
need  ever  be  abandoned  because  the  adhesions  are  sup- 
posed to  present  an  insuperable  obstacle.     I  have,  on 


General  Observations 


305 


many  occasions,  seen  adhesions  that  at  first  were  utterly 
bewildering  in  their  infinite  complexity,  but  gentle  per- 
sistence in  separating  first  one  spot  and  then  another  has 
gradually  cleared  all  difficulties  away. 


Fig  63. — Liver  rotated  through  Mayo  Robson's  incision  When 
the  gall-bladder  is  pulled  upwards  in  this  way,  the  ducts  are  straight- 
ened and  put  upon  the  stretch.      Access  to  them  is  then  quite  easy. 


When  all  is  quite  clear,  then  the  gall-bladder  with  the 
liver  around  it  is  seized  in  the  hand  covered  with  gauze, 
and  gently  dragged  downwards  from  under  the  shelter  of 
the  ribs.  If  this  can  be  effected,  it  will  be  found  easy  to 
rotate  the  liver,  turning  the  gall-bladder  upwards,  so  that 


3o6    Operations  on  Gall-bladder  and  Bile-ducts 

what  was  its  under  surface  now  faces  upward  and  forwards. 
By  this  manoeuvre  the  cystic  and  common  ducts  are 
brought  almost  into  a  straight  line,  and  the  common  duct, 
which  at  first  seemed  so  deeply  hidden  in  the  abdomen, 
can  now  be  brought  forwards  till  it  lies  almost  or  actually 
on  a  level  with  the  skin.  In  this  way  the  ducts  can  be 
most  thoroughly  explored  and  the  surgeon  may  satisfy 
himself  of  the  certainty  of  being  able  to  remove  all  the 
stones. 

It  is  not  necessary  in  all  cases  to  bring  the  liver  and 
gall-bladder  forward  in  this  way,  but  in  case  of  any 
doubt,  it  is  certainly  advisable  to  do  so.  In  thin  patients 
this  may  be  done  through  the  usual  vertical  incision,  but 
in  the  stouter  patients  the  upward  and  inward  prolonga- 
tion of  the  incision  will  first  be  necessary. 

In  stout  people  it  is  sometimes  difficult  to  make  the 
liver  rotate,  and  thus  to  bring  the  ducts  forward,  but 
even  if  the  manoeuvre  cannot  be  completely  effected,  it 
can  often  be  done  to  such  an  extent  as  to  make  the  steps 
of  the  operation  much  easier.  If  the  patient  be  thin,  and 
if,  as  in  spare  women,  the  liver  lies  with  its  edge  well 
below  the  costal  margin,  it  is  perfectly  easy  to  bring  the 
common  duct  well  up  to,  or  even  outside,  the  abdominal 
wound,  and  there  to  incise  or  suture  it. 

During  the  operation  it  is  advisable  in  all  cases,  but 
more  especially  in  those  patients  suffering  from  chronic 
jaundice,  to  ligature  every  bleeding  point. 

After  the  intra-abdominal  portion  of  the  operation  is 
completed  it  is  necessary  to  remove  the  sand-bag  from 
beneath  the  patient's  back  before  stitching  the  wound. 
The  peritoneal  stitch  is  excessively  difficult  to  introduce 


General  Observations  307 

while  the  epigastrium  is  made  tense  and  prominent  by 
the  sand-bag. 

The  preliminary  treatment  of  patients  who  are  to  be 
operated  upon  for  gall-stone  disease  is  the  same  as  in  all 
abdominal  operations.  In  cases  of  chronic  jaundice 
Mayo  Robson,  acting  upon  the  experimental  observations 
of  Wright,  has  administered  chloride  of  calcium,  either 
by  the  mouth  or  by  the  rectum,  in  the  hope  that  the 
coagulability  of  the  blood  might  thereby  be  increased. 
I  have  never  been  convinced  that  this  drug  had  any 
effect  whatever  in  this  direction,  and  though  I  formerly 
gave  it  a  fair  trial,  I  have  now  ceased  to  administer  it. 

In  some  few  cases  I  have  given  gelatine  subcutaneously 
with  the  same  hope — but  this  also  I  have  abandoned  as 
being  useless. 

The  abdominal  wound  is  closed  in  the  follow^ing 
manner : 

The  parietal  peritoneum  is  seized  on  each  side  with 
two  or  three  pairs  of  clips  which  hold  the  cut  edge  of  the 
peritoneum  and  also  the  posterior  sheath  of  the  rectus 
muscle.  The  clips  are  given  to  an  assistant,  who  holds 
them  away  from  the  abdominal  wound  with  sufficient 
force  to  facilitate  the  ready  introduction  of  the  stitch. 
Too  forcible  a  drag  must  not  be  made,  or  the  clip  will  be 
pulled  away.  A  continuous  catgut  suture  is  now  intro- 
duced, beginning  at  the  lower  end  of  the  wound.  It  takes 
up  on  each  side  the  posterior  sheath  and  the  peritoneum 
together.  If  the  rectus  is  very  thick,  a  portion  of  this  may 
also  be  included.  This  is  much  better  than  the  practice 
usually  followed  of  seizing  only  the  peritoneum,  for  if 
there  be  anv  tension  on  the  stitches,  the  needle  mav  cut 


3o8    Operations  on  Gall-bladder  and  Bile-ducts 

through,  or  the  stitch,  after  being  tightened,  may  break 
away.  This  stitch  is  continued  from  the  lower  end  of 
the  incision  to  the  top  if  the  wound  is  to  be  closed  com- 
pletely. If  a  drainage-tube  is  left  in  the  wound,  the 
stitch  is  continued  up  to  the  tube.  The  same  stitch 
having  reached  the  upper  end  of  the  wound,  or  the 
tube,  is  now  introduced  from  above  downwards,  seizing 
the  rectus  muscle  and  the  anterior  sheath ;  when  the  lower 
end  of  the  wound  is  reached,  the  end  of  the  suture  is  tied 
to  that  end  which  was  left  long  when  the  stitch  was 
begun.  The  stitch  is  carefully  introduced  and  accurate 
apposition  ensured.  In  thin  patients  this  suture  is  quite 
enough  to  ensure  a  firm  cicatrix,  but  in  stout  patients, 
or  in  any  patients  whom,  because  of  old  age  or  feebleness 
or  old-standing  chest  disease,  I  may  wish  to  get  out  of 
bed  within  three  or  four  days  of  the  operation,  I  first  in- 
troduce a  series  of  deep  silkworm-gut  sutures.  These  are 
introduced  about  one-half  of  an  inch  from  the  margin  of 
the  wound ;  they  pass  through  all  the  structures  of  the 
abdominal  wall  except  the  peritoneum,  being  brought 
out  on  the  one  side  and  re-introduced  on  the  other  between 
the  posterior  rectus  sheath  and  the  peritoneum.  These 
sutures  are  placed  about  three-fourths  of  an  inch  apart. 
They  are  not  tightened  until  the  catgut  suture  has  been 
passed,  as  already  described.  When  this  catgut  suture 
is  completed  and  its  ends  cut  short,  the  silkworm-gut 
sutures  are  knotted.  It  is  not  necessary — it  is,  in  fact, 
harmful — to  draw  them  very  tight.  As  long  as  they  draw 
the  opposing  walls  comfortably  together,  that  is  all  that 
is  needed.  Tension  is  to  be  avoided.  A  continuous 
stitch  of  thin  Pagenstecher  thread  is  now  introduced  close 


Cholecystotomy  309 

to  the  wound  edges  to  ensure  accurate  skin  apposition. 
However  carefully  interrupted  sutures  are  passed  there 
is  a  risk  of  having  overlapping  of  the  skin  edge,  and, 
therefore,  delay  in  the  sound  and  perfect  healing  of  the 
wound.  For  this  suture  a  triangular  pointed  straight 
needle  is  used. 


THE  OPERATIVE  TREATMENT  OF  STONES  IN  THE  GALL- 
BLADDER. 

When  stones  are  present  in  the  gall-bladder,  they  may 
be  removed  by  cholecystotomy  or  by  cholecystectomy. 
The  operations  well  be  separately  considered. 

CHOLECYSTOTOMY. 

Indications  for  the  Performance  of  the  Operation  of 
Cholecystotomy. — Cholecystotomy  is  the  operation  most 
commonly  practised  at  the  present  day  for  stones  which 
are  found  in  the  gall-bladder.  Under  certain  circum- 
stances it  has  been  replaced  by  the  operation  of  cholecys- 
tectomy. As  to  the  conditions  which  demand  the  latter 
operation,  and  as  to  those  in  which  it  will  probably  be 
the  operation  of  choice,  I  propose  to  speak  later.  There 
are,  however,  certain  cases  for  which  cholecystotomy 
will  always  remain  the  only  satisfactory  operative  pro- 
cedure. Though  the  experience  of  many  surgeons 
seems  to  be  urging  them  to  perform  cholecystectomy 
far  more  frequently  than  before,  there  will  always 
be  some  cases  for  which  cholecystotomy  must  be  per- 
formed. The  need  for  this  particular  operation  will 
be    determined  in   part   by  the    conditions  found  when 


3IO    Operations  on  Gall-bladder  and  Bile-ducts 

the  abdomen  is  opened  and  the  bile  passages  ex- 
plored, but  more  often  by  the  general  condition  of 
the  patient.  In  not  a  few  gall-stone  operations,  es- 
pecially in  older  people  suffering  from  a  severe  infec- 
tion, that  operation  is  the  most  desirable  which  gives 
the  speediest  relief.  It  is  not  a  permanent  cure  of  the 
disease  that  at  such  a  moment  is  the  surgeon's  chief  de- 
sire, but  rather  some  quick  and  assured  means  of  giving 
relief  to  urgent  and  threatening  symptoms,  so  that  the 
patient  may  be  brought  safely  through  a  time  of  great 
peril.  When  the  danger  is  past,  then  a  further  step 
towards  the  permanent  cure  of  the  condition  may,  if 
necessary,  be  safely  taken.  Broadly  speaking,  there- 
fore, cholecystotomy  will  be  demanded  where  there  are 
the  acute  infective  conditions  for  which  instant  relief 
is  necessary  and  in  patients  whose  powers  of  withstand- 
ing the  shock  of  any  detailed  operative  procedures  are 
small.  That  surgeon  will  have  the  best  results  who  does 
not  always  follow  any  method,  but,  taking  a  just  measure 
of  his  patient's  powers,  chooses  that  measure  of  relief 
which  seems  to  him,  in  each  case,  to  be  the  best ;  one  in  the 
practice  of  which  he  is  the  most  expert.  This  is  more 
especially  the  case  in  gall-stone  surgery,  for  so  many  con- 
ditions, each  one  a  menace  to  the  patient's  life  or  comfort, 
may  be  present  at  the  same  time.  A  stone  in  the  am- 
pulla, infectious  cholangitis,  cholecystitis  with  ulceration 
of  stones  into  the  liver,  for  example,  were  present  in  two 
consecutive  cases  of  my  own.  For  the  gall-bladder  con- 
dition alone,  cholecystectomy  would  have  been  correct. 
But  whether  in  such  circumstances  it  should  be  done  in 
the  presence  of  the  other  conditions  will  depend  upon  the 


Cholecystotomy  311 

patient's  condition,  the  difficulties  or  the  ease  of  that 
particular  operation,  the  surgeon's  former  experience,  and 
so  forth.  In  these  two,  I  performed  transduodenal 
choledochotomy  and  cholecystectomy,  and  after  taking 
away  the  cystic  duct,  I  left  a  tube  in  the  common  and 
hepatic  ducts.  Both  patients  recovered.  To  have  at- 
tempted such  an  operation  in  old  or  weakly  patients 
would  have  been  worse  than  folly. 

One  point  which  requires  further  investigation  is  as  to 
the  frequency  and  the  character  of  the  after-results  of 
cholecystotomy.  It  is  desirable  that  we  should  know  of 
the  frequency  of  recurrence  of  gall-stones  (and  this  should 
be  distinguished  from  the  spurious  recurrence  which  is 
the  sequel  of  incomplete  removal  of  stones),  and  of  the 
symptoms  that  ensue  when  adhesions  have  formed  to  a 
chronically  inflamed  gall-bladder,  even  after  all  stones 
have  been  removed.  Of  the  former  some  evidence  is 
forthcoming,  though  no  doubt  it  is  not  all  available; 
of  the  latter  there  is  also  evidence,  and  Fiirbringer 
(Arch.  f.  phys.  u.  diat.  Therap.,  July,  1903)  has  said 
that  "post-operative  adhesions  to  the  gall-bladder 
embitter  the  lives   of    many  patients." 

The  majority  of  surgeons  will  agree  with  Dr.  Maurice 
Richardson  when  he  says  (Med.  News,  ]\Iay  2,  1903,  p. 
817):  "The  end-results  in  simple  cholecystotomy  are 
certainly  as  gratifying  as  end-results  have  ever  been  in 
any  class  of  abdominal  operations." 

Operation. — The  operation  of  cholecystotomy  has 
been  practised  in  two  ways:  In  one,  the  gall-bladder, 
after  being  opened  and  cleared  of  stones,  is  stitched 
up    and    returned    within    the    abdomen;    this  method 


312    Operations  on  Gall-bladder  and  Bile-ducts 

is  known,  most  inappropriately,  as  "ideal"  chole- 
cystotomy,  or  as  cholecystendesis  (Courvoisier).  In 
the  other  method  the  gall-bladder  is  opened,  emptied, 
and  stitched  to  the  abdominal  wall  in  such  a  way  that 
drainage  through  the  incision  is  permitted.  The  former 
method,  first  performed  by  Meredith  in  1883,  is  rarely,  if 
ever,  practised  by  experienced  surgeons  now. 

Since  it  has  been  recognised  that  many  of  the  symp- 
toms and  all  of  the  complications  of  gall-stone  disease  are 
due  to  an  inflammation  in  the  gall-bladder  or  bile-ducts, 
it  has  properly  become  the  custom  to  drain  the  bile 
passages  until  the  time,  varying  in  different  cases,  when 
the  inflammatory  processes  have  subsided.  The  great 
principle  which  has  to  be  carried  out  in  gall-stone 
surgery  is  drainage.  Without  drainage  there  is  a  risk 
of  imperfect  healing  of  wounds  made  in  the  bile 
passages,  and,  therefore,  of  leakage  subsequently  of 
their  contents,  of  small  calculi  or  sand  or  inspissated 
bile,  or  even  pus  remaining,  and  of  that  condition 
of  the  mucosa  persisting  (stone-forming  catarrh)  which 
was  responsible  in  the  first  instance  for  the  forma- 
tion of  gall-stones.  "Ideal  cholecystotomy"  is  any- 
thing but  ideal  in  practice,  and  is  an  operation 
that  is  mentioned  now  only  that  it  may  be  une- 
quivocally condemned. 

Cholecystotomy  is  performed  in  the  following  manner: 
When  the  abdomen  has  been  opened  in  the  manner  al- 
ready described,  and  the  gall-bladder  and  ducts  and  the 
head  of  the  pancreas  thoroughly  explored  and  freed  from 
all  adhesions,  the  operative  area  is  packed  round  with 
gauze  swabs  wrung  out  of  hot  sterile  salt  solution.     If 


Cholecystotomy 


J^O 


the  gall-bladder  is  of  moderate  or  large  size,  it  will  be 
found  quite  easy  to  draw  the  fundus  up  into  the  wound. 
An  aspirating  needle  is  now  thrust  into  the  fundus  of 
the  gall-bladder  and  all  the  fluid  contents  drawn  away. 
While  this  is  done,  the  fundus  should  be  seized  with  a 
Spencer  Wells  clip  on  each  side  of  the  puncture,  to  steady 
the  gall-bladder  and  to  hold  it  forward  when  it  is  empty 
and  perhaps  collapsed,  so  that  it  does  not  slip  away  when 
the  needle  is  withdrawn.  The  fluid  removed  from  the 
gall-bladder  should  be  considered  septic.  The  needle, 
therefore,  which  has  been  within  the  bladder  should 
not  be  touched,  nor  should  any  drop  of  exudate  from  the 
puncture  be  allowed  to  soil  the  hands  or  any  portion  of 
the  wound.  The  swabs  used  to  mop  the  puncture,  or 
those  which  in  a  later  stage  are  soiled  with  the  fluid  from 
the  bladder,  should  at  once  be  thrown  away.  The 
puncture  in  the  fundus  is  now  enlarged  with  a  snip  of 
the  scissors  until  an  opening  about  one-half  of  an  inch  or 
even  longer  is  made.  The  clips  which  hold  the  fundus  at 
each  side  of  this  incision  are  now  removed  and  reapplied 
so  that  the  edge  of  the  incision  is  seized.  By  their  means 
the  wound  can  now  be  held  opened,  or  when  they  are 
crossed  over,  can  be  securely  closed.  Through  this  open- 
ing a  large  gall-stone  scoop  is  introduced,  and  the  stones 
removed.  If  there  are  many  stones,  it  is  advisable  to 
remove  only  a  few  at  a  time;  if  the  scoop  be  overfull, 
it  is  difficult  to  withdraw  from  the  gall-bladder  and  some 
of  the  stones  may  fall  away  into  the  swabs,  and  will  have 
to  be  sought.  It  will  often  be  found  that  if  many  stones 
are  present  in  the  gall-bladder,  the  smaller  ones  will  be 
near  the  fundus  and  one  or  more  larger  ones  will  lie  in  the 


314    operations  on   Gall-bladder  and   Bile-ducts 

pelvis,  near  to  but  not  occluding  the  opening  into  the 
cystic  duct.  When  all  the  stones  that  can  be  felt  with 
the  scoop  are  removed,  the  clips  on  the  edge  of  the  opening 
are  crossed  so  as  to  pull  the  edges  together,  and  the  fundus 


Fig.  64. — Shewing  the  drainage-tube  fixed  in  the  gall-bladder  by 
a  single  catgut  suture  and  the  method  of  infolding  the  edges  of  the 
wound   in   the    gall-bladder. 


of  the  gall-bladder  is  wrapped  in  gauze.  The  swabs  which 
lie  beneath  the  bladder  are  then  removed  or  pushed 
aside,  and  while  the  left  hand  holds  the  gall-bladder, 
the  fingers  of  the  right  hand  are  slipped  along  the  under 
surface  and  the  ducts  are  again  explored.  If  a  stone  or 
stones  be  felt  in  the  cystic  or  hepatic  ducts,  an  attempt  is 


Cholecystotomy 


15 


made  to  "milk"  them  backwards  into  the  gall-bladder. 
If  any  difficulty  is  experienced  with  a  stone  in  the  pelvis 
or  in  the  cystic  duct,  the  scoop  may  be  re-introduced, 
and  may  be  worked  within  the  bladder  in  concert  with 
the  fingers  outside.  In  this  fashion  a  stone  which  is 
seemingly  imprisoned  may  be  dislodged.  When  all  stones 
are,  so  far  as  can  be  seen,  entirely  cleared  away,  a  final 
examination  of  the  duct 
is  again  made,  and  if 
they  are  found  to  be 
clear,  the  swabs  may  be 
removed  from  the  kid- 
ney pouch  and  from 
above  the  stomach,  one 
swab  only  being  left  be- 
neath the  centre  of  the 
wound.  A  tube  is  now 
introduced  into  the  gall- 
bladder. The  size  most  often  used  is  about  one- 
third  of  an  inch  in  diameter.  About  two  to  three 
inches  are  laid  within  the  gall-bladder,  so  that  the 
end  of  the  tube  reaches  approximately  to  the  pelvis. 
The  tube  is  now  fixed  by  a  single  catgut  stitch  which 
passes,  on  the  one  hand,  through  all  the  coats  of  the 
gall-bladder  except  the  mucosa  just  beyond  the  edge  of 
the  opening,  and,  on  the  other,  through  the  tube.  This 
is  tied,  and  the  tube  thereby  is  fixed  firmly.  The  incision 
and  this  stitch  are  now  buried  in  one  of  two  ways :  either 
by  taking  a  purse-string  suture  around  the  wound  and 
tightening  this,  as  the  tube  is  pushed  deeper  into  the 
gall-bladder,  as  is  done  in  Senn's  method  of  gastrostomy, 


Fig.  65. — Gall-bladder  closed 
around  drainage-tube  by  means  of  a 
purse-string  suture. 


31 6    Operations  on  Gall-bladder  and  Bile-ducts 

or  a  continuous  stitch  is  taken  from  side  to  side  of  the  in- 
cision, taking  all  the  coats  except  the  mucosa,  so  that  on 
drawing  this  tight  the  edges  are  infolded,  as  in  Kader's 
method  of  gastrostomy.  The  stitches  in  either  case 
are  made  to  embrace  the  tube  closely  so  that  no  leakage 

can  occur  by  its  side. 
a  b  The  swab   within   the 

abdomen  is  now  re- 
moved, and  the  ab- 
dominal wound  closed 
in  the  usual  manner. 
The  gall-bladder  may 
be  allowed  to  fall  back 
within  the  abdomen, 
or,  preferably,  it  may 
be  fixed  to  the  parietal 
peritoneum  in  the  fol- 
lowing way :  The  con- 
tinuous suture  of  cat- 
gut which  is  first  in- 
troduced to  suture  the 
'^-■^  ^  peritoneum     and     the 

Fig.  66  —Drainage-tubes:  a,  Split  posterior  sheath  of  the 

rubber  tube  with  gauze  wick;  b,  the 
rolled  tube  of  gauze  and  dental  rub-  rectUS  is  begun  at  the 

^^'^-  lower      end      of      the 

wound.  When      it 

reaches  the  middle  or  a  little  above  the  middle,  the 
needle  is  passed  through  the  wall  of  the  gall-bladder, 
avoiding  the  mucosa,  as  it  crosses  from  the  left  to  the 
right  edge  of  the  wound.  The  stitch  then  returns  to  the 
lower  end  of  the  wound,  taking  the  anterior  sheath  of  the 


Operations  for  Stone  in   Cystic  Duct         317 

rectus.  The  upper  part  of  the  wound,  that  which  Hes 
above  the  tube,  is  similarly  treated,  the  stitch  now  begin- 
ning at  the  top  of  the  wound  and  working  downwards 
to  the  middle  until  the  gall-bladder  is  reached,  when,  as 
before,  a  single  suture  is  passed  through  it.  The  gall- 
bladder is  then  held  by  two  stitches,  one  above,  one 
below.  There  is  no  need  to  fix  the  gall-bladder  by 
interrupted  sutures  closely  placed  together,  or  even  by  a 
continuous  suture.  The  two  stitches  passed  in  the 
way  described  suspend  the  gall-bladder  quite  sat- 
isfactorily. 


THE  OPERATIVE  TREATMENT  OF  STONE  IN  THE  CYSTIC 

DUCT. 

When  a  stone  is  present  in  the  cystic  duct,  it  may  be 
loosely  fixed,  being  contained  in  a  pouch  or  diverticulum, 
and  interfering  very  little  with  the  passage  of  bile  and 
mucus,  or  it  may  be  tightly  wedged  in  the  duct  and  in  this 
way  may  cause  a  condition  of  hydrops  or  of  empyema, 
or,  in  the  latest  stage,  of  cysto-intestinal  fistula.  A  stone 
wedged  in  the  pelvis  of  the  gall-bladder  is  not  to  be 
distinguished  from  a  stone  in  the  cystic  duct,  for,  when 
it  has  been  long  stationary,  the  gall-bladder  may  narrow 
behind  it,  forming  an  "  hour-glass  gall-bladder,"  the 
pouch  in  which  the  stone  is  lying  then  resembling  a 
dilated  cystic  duct. 

When  the  stone  is  found  in  the  cystic  duct,  it  may  be 
dealt  with  by  crushing,  cholelttJiotrity,  by  incision  of  the 
duct,  cysticotomy,  followed  by  suture  of  the  duct  or 
drainage,    or    by    cholecystectomy,    the    gall-bladder    and 


3i8    Operations  on  Gall-bladder  and  Bile-ducts 

cystic  duct  being  removed  in  mass  or  by  cholecystot- 
omy. 

Of  the  operation  of  cholelitJiotrity,  whether  for  stone  in 
the  cystic  or  for  stone  in  the  common  duct,  I  have  not 
had,  and  I  do  not  anticipate  that  I  shall  have,  any  ex- 
perience. The  method  seems  to  me  to  be  one  that  was 
only  fitted  for,  perhaps  compulsory  in,  the  earliest  days 
of  the  operative  treatment  of  gall-stones.  But  at  the 
present  time  it  is  rarely  if  ever  necessary,  and  should  only 
be  reserved  for  those  cases  where  any  other  method  of 
removal  seems  impossible  or  extremely  hazardous.  The 
disadvantages  of  the  method  are  that  it  is  likely  to 
damage  the  duct,  and  therefore,  perhaps,  to  lead  to  rup- 
ture, ulceration,  or  stenosis,  that  it  is  uncertain, — other 
stones  being  overlooked  and  left  untreated, — and  that 
some  fragments  of  the  crushed  stone  may  remain  behind 
to  form  the  nucleus  of  other  stones.  It  is,  in  fact,  a  crude 
and  imperfect  method.  The  needling  of  a  stone  or  stones 
through  the  duct  wall  finds  no  place  in  the  surgery  of 
to-day. 

Cysticotomy.  — The  removal  of  stones  from  the  cystic 
duct  through  an  incision  which  is  subsequently  sutured, 
or  into  which  a  drainage-tube  is  introduced  is  an  operation 
that  is  occasionally,  though  rarely,  necessary.  The 
operation  was  first  performed  by  Lindner  in  1891  upon  a 
patient  from  whom  he  also  removed  the  gall-bladder. 
Kehr  in  1892  removed  a  stone  from  the  duct  and  closed 
the  opening  by  suture,  draining  the  gall-bladder. 

The  neck  of  the  gall-bladder  and  the  cystic  duct  are 
exposed  by  the  method  of  rotation  of  the  liver  already 
described.     When  the  duct  is  exposed,  it  is  incised,  the 


Cysticotomy  319 

stone  or  stones  removed,  and  a  further  exploration  of  the 
duct  made  at  once.  If  the  bile  passages  are  found  to  be 
clear,  the  wound  may  be  closed  by  a  continuous  catgut 
suture  which  misses  the  mucosa.  This  will  close  the 
incision  satisfactorily,  but  a  second  supporting  layer  of 
sutures,  either  of  catgut  or  preferably  of  thin  celluloid 
thread,  should  also  be  introduced.  A  drain  is  then 
placed  in  the  gall-bladder  and  the  abdominal  wound  is 
closed  in  the  usual  way. 

When  the  stone  is  tightly  wedged  in  the  duct  and 
hydrops  or  empyema  has  resulted,  the  operation  to  be 
practised  will  depend  very  much  upon  the  general  condi- 
tion of  the  patient  and  upon  the  especial  conditions  found 
when  the  field  of  operation  is  exposed.  As  a  rule, 
cholecystectomy  should  be  performed.  It  is  the  operation 
I  perform  as  the  routine  procedure,  in  the  absence  of 
special  circumstances  which  would  add  an  undue  risk 
to  its  performance.  I  have  removed  the  gall-bladder  and 
the  cystic  duct  upon  several  occasions  for  these  condi- 
tions, and  the  results  have  been  remarkably  good.  In 
seven  cases  of  empyema  I  have  lost  one  patient,  on  the 
.  eleventh  day,  from  suppression  of  urine,  and  of  five  cases 
of  hydrops  I  have  not  lost  one,  and  in  one  case  of  gangrene 
of  the  gall-bladder  the  patient  recovered. 

If,  however,  the  condition  of  the  patient  is  poor  and  her 
power  of  bearing  any  operation  is  but  small,  or  if  the 
gall-bladder  be  adherent,  or  the  mechanical  difficulties 
of  the  operation,  owing  to  thickness  of  the  abdominal 
walls,  be  considerable,  cJiolecystotomy  should  be  per- 
formed. 

It  will  be  found  helpful,  then,  to  aspirate  the  contents 


320    Operations  on   Gall-bladder  and   Bile-ducts 

of  the  distended  gall-bladder  very  slowly.  If  the  fluid 
is  quickly  withdrawn,  it  will  be  found  that  the  gall- 
bladder contracts  rapidly  on  to  the  stone  and  forms  a 
tight  constriction  on  the  distal  side  of  it.  If,  however,  the 
fluid  be  withdrawn  slowly  and  the  operator  keeps  his 
fingers  on  the  stone,  he  may  be  able  to  squeeze  the  stone 
backwards  into  the  gall-bladder,  which  is  still  moderately 
distended  with  fluid.  The  gall-bladder  should  never  be 
emptied  until  a  very  thorough  attempt  at  displacing  the 
stone  has  been  made.  This  little  manoeuvre  is  one  the 
use  of  which  I  have  experienced.  The  reason  for  its 
success  is  easy  to  understand.  The  fact  that  the  stone 
has  been  displaced,  and  that,  therefore,  the  cystic  duct 
is  clear,  will  be  appreciated  when  bile  is  seen  to  flow  from 
the  gall-bladder.  After  dislodging  the  stone,  the  gall- 
bladder may  be  drained  as  in  the  ordinary  method  of 
cholecystotomy,  or  the  gall-bladder  may  be  removed. 

If  it  is  found  impossible,  after  persistent  efforts,  to 
dislodge  the  stone,  the  operation  of  cysticotomy  is  per- 
formed, or  the  gall-bladder  is  drained  and  the  abdominal 
wound  is  closed.  The  tube  used  for  draining  the  gall- 
bladder should  be  of  large  size — half  an  inch  or  even  more 
in  diameter.  After  the  lapse  of  a  few  days  the  stone  may 
be  dislodged  spontaneously.  If  it  is  not,  then  the  tube 
may  be  removed,  and  the  gall-bladder  be  syringed  with 
hot  sterile  salt  solution,  or  with  olive  oil,  or  soap  solutions. 
In  one  or  other  of  these  ways  the  stone  may  be  displaced, 
or  it  is  supposed,  in  part,  dissolved.  Even  after  seven- 
teen days,  as  in  one  of  my  earliest  cases,  the  stone  may 
move  into  the  gall-bladder  and  escape  from  the  wound. 


Treatment  of   Biliary  Fistulae  321 

A  biliary  fistula  is  then  left,  which  closes  spontaneously 
in  the  usual  manner. 

If  the  stone  remains  unmoved,  then  a  mucous  fistula 
persists.  These  fistulae  were  much  more  commonly  seen 
in  the  early  days  of  gall-stone  surgery  than  they  are  now. 
When  they  exist,  it  is  for  the  patients  to  decide  whether 
the  discomfort  thereby  caused  is  great  enough  to  compel 
them  to  undergo  a  further  operation  for  their  relief.  As 
a  rule,  they  cause  but  trivial  inconvenience.  Their  treat- 
ment by  operation  consists  in  destroying  the  mucous 
membrane  of  the  gall-bladder  either  by  the  scraper  or  by 
the  cautery,  or  by  the  knife  or,  and  this  in  preference, 
by  making  a  further  attempt  at  the  removal  of  the  im- 
pacted stone,  and,  failing  that,  by  performing  the  opera- 
tion of  cholecystectomy  and  removing  the  cystic  duct 
entirely. 

Treatment  of  Biliary  Fistulae. — If,  in  operating  upon  a 
patient  for  gall-stone  disease,  a  fistula  be  found  between 
any  part  of  the  intestinal  canal,  on  the  one  hand,  and  the 
gall-bladder  and  cystic  duct,  on  the  other,  the  adherent 
and  communicating  viscera  should  be  separated.  This 
must  be  done  with  great  gentleness  so  that  no  unneces- 
sary damage  is  done  to  the  stomach  or  intestine.  When 
a  complete  separation  has  been  made,  the  opening  into 
the  intestine  must  be  trimmed  and  its  closure  securely 
effected  by  suture.  As  a  rule,  a  continuous  suture  of 
catgut,  embracing  all  the  coats  of  the  gut,  and  outside 
this  a  continuous  suture  of  fine  Pagenstecher  thread,  will 
prove  the  most  satisfactory  method  of  closure.  The 
opening  in  the  gall-bladder  or  in  the  cystic  duct  may  be 
closed  by  suture,  it  may  be  drained,  or  preferably,  the 


322     Operations  on   Gall-bladder  and   Bile-ducts 

gall-bladder  and  the  cystic  duct  together  may  be  removed, 
as  in  the  cases  under  my  own  care  to  which  reference  has 
already,  been  made. 


CHOLECYSTECTO.VIY. 

Indications  for  the  Performance  of  Cholecystectomy. — 

In  1902  I  read  a  paper  entitled  "A  Series  of  Cases  of 
Cholecystectomy, ' ' '  before  the  Yorkshire  Branch  -lof  the 
British  Medical  Association.  I  gave  then  the  followmg 
indications  for  the  performance  of  this  operation: 

1.  In   injuries    of   the   gall-bladder,    rupture,    stab   or 

bullet  wounds. 

2.  In  gangrene  of  the  gall-bladder. 

3.  In  phlegmonous  cholecystitis. 

4.  In  membranous  cholecystitis. 

5.  In  chronic   cholecystitis  with   dense   thickening  of 

the  walls  of  the  gall-bladder  and  cystic  duct,  with 
or  without  stenosis  of  the  cystic  duct,  and  in 
chronic  cholecystitis,  when  the  gall-bladder  is 
shrivelled  and  puckered  and  universally  ad- 
herent. In  such  cases  it  is  no  longer  a  receptacle 
for  the  bile. 

6.  In  distension  of  the  gall-bladder,  hydrops  of  empy- 

ema, due  to  blockage  of  the  cystic  duct  by  calculus, 
stricture,  growth  or  external  inflammatory  de- 
posits; or  in  cases  of  mucous  fistula  following 
operations  for  these  conditions. 

7.  In  cases  of  fistula  between  the  gall-bladder  or  the 

cystic  duct,  on  the  one  hand,  and  the  stomach, 
duodenum,  or  colon,  on  the  other. 

8.  In  multiple  ulcerations  of  the  gall-bladder  or  the 

cystic   duct   when   gall-stones   have   eroded   their 


Cholecystectomy  323 

way  through   the   walls   into   the   liver,  the   duo- 
denum, or  other  protective  adherent  masses. 
9.   In  primary  carcinoma  of  the  gall-bladder. 


The  result  of  my  early  cases  was  so  satisfactory  that  I 
was  led  to  put  the  operation  to  a  more  extended  proof, 
and  as  my  experience  increases  I  am  tempted  to  ask 
whether  it  would  not  be  the  better  treatment  in  many 
gall-stone  operations  to  remove  the  gall-bladder  entirely. 

The  experience  of  every  surgeon  who  has  worked  ex- 
tensively in  this  field  of  surgery  is  that  the  chief  purpose 
and  the  main  indication  in  any  operation  for  gall-stones 
is  the  drainage  of  the  gall-bladder  and  bile-ducts.  Of 
the  validity  of  this  experience  there  can  be  no  question. 
We  know  that  gall-stones  are  rendered  troublesome  by 
the  cholecystitis  or  the  cholangitis  which  they  are  the 
means  of  arousing.  In  many  cases  it  is  because  of  the 
inflammatory  consequences  that  an  operation  is  de- 
manded. The  essential  part  of  any  operation  would, 
therefore,  seem  to  be  the  drainage  of  the  gall-bladder, 
prolonged  for  such  a  time  as  to  allow  a  complete  subsid- 
ence of  the  inflammatory  process.  But  in  the  ver}^  great 
majority  of  cases  the  secondary  inflammation  has  its 
origin,  and  runs  its  course  entirely  within  the  gall-bladder ; 
an  infection  of  the  hepatic  or  common  ducts  does  not 
occur.  In  many  cases,  therefore,  in  removing  the  gall- 
bladder, we  are  doing  away  with  the  necessity  for  drain- " 
age  by  removing  that  structure,  the  drainage  of  which 
seemed  imperative.  It  is  within  the  gall-bladder  that 
the  great  majoritv  of  stones  are  formed;  it  is  within  the 
gall-bladder  that   the   secondarv  inflammatorv  troubles 


324    Operations  on  Gall-bladder  and  Bile-ducts 

break  out,  and,  in  the  majority  of  cases,  are  altogether 
limited.  The  removal  of  the  gall-bladder,  therefore, 
does  away  with  the  need  for  drainage.  It  renders  less 
likely  the  formation  of  gall-stones,  and  it  renders  less 
likely  the  inflammatory  consequences  of  their  presence. 
If,  however,  the  need  for  drainage  is  absolute,  it  is 
possible,  in  fact  quite  easy,  to  drain  the  ducts  after  the 
gall-bladder  has  been  removed.  After  the  division  of 
the  cystic  duct  the  stump  of  the  duct  may  be  slit  up  until 
the  hepatic  duct  is  reached,  or  the  cystic  duct  may  be 
cut  off  flush  with  the  common  duct.  It  is  then  quite  a 
simple  matter  to  explore  upwards  and  downw^ards  with  a 
gall-stone  scoop  or  with  the  finger  to  make  certain  that 
the  ducts  are  clear  of  calculi,  and  then  to  stitch  in,  by  a 
single  catgut  suture,  a  rubber  drainage-tube.  The  presence 
of  stones  in  the  common  duct  does  not  debar  one  from 
removing  the  gall-bladder.  In  two  cases  I  have  removed 
stones  from  the  ampulla  of  \"ater  by  duodeno-chole- 
dochotomy  and  have  then  at  once  removed  a  chronically 
inflamed  gall-bladder  full  of  stones  which  were  ulcerat- 
ing into  the  liver,  and  after  dividing  the  cystic  duct 
to  the  common  duct,  have  stitched  in  a  rubber  drainage- 
tube.  Both  patients  recovered  without  the  slightest 
interruption.  The  plea,  therefore,  that  the  need  for 
drainage  is  opposed  to  the  routine  removal  of  the  gall- 
bladder is  answered  by  the  facts  that  when  the  gall- 
bladder is  removed,  the  need  for  drainage  does  not  often 
exist,  as  that  need  was  due  to  the  presence  of  the  gall- 
bladder and  that  if  desirable  or  necessary,  it  can  be  car- 
ried out  without  the  smallest  difficulty. 

An  examination  into  the  recorded  cases  of  carcinoma  of 


Cholecystectomy  325 

the  gall-bladder  and  of  the  adjacent  portions  of  the  liver 
shews  that  in  approximately  95  per  cent.,  the  malignant 
change  is  due  to  the  chronic  irritation  of  gall-stones.     If 
the  gall-bladder  is  removed,  there  will,  of  course,  be  no 
chance  of  this  malignant  grow^th  occurring.     This  is  not, 
however,  a  point  of  much  importance,  for  the  cases  of 
carcinoma  are,  as  a  rule,  those  in  which  no  operation  has 
been  done;   by  the  time  the  surgeon  sees  the  cases  the 
growth   is   already   there.     To  make  the  argument  for 
cholecystectomy  a  strong  one  from  this  point  of  view,  it 
would  be  necessary  to  shew  that  malignant  disease  oc- 
curred after  cholecystotomy,  and,  so  far  as  I  know,  this 
had  not  been  done  at  the  time  my  paper,  already  referred 
to,  was   written.     Since   then,   however,    my   colleague, 
Mr.  Lawford  Knaggs,  has  recorded  an  exemplary  instance 
of  this.     The  case  is  given  at  length  in  the  chapter  dealing 
with   the   "General    Pathology   of   Gall-stone    Disease." 
A  similar  instance  is  recorded  by  Mr.  Mayo  Robson.     The 
patient  was  a  lady  aged  fifty-seven,  upon  whom  chole- 
cystectomy was  performed  in  February,  1902.     A  good 
recovery  followed,  and  the  patient  remained  well  up  to 
August,  1903,  except  for  pain  in  the  gall-bladder.     On 
examination,   a  tender  lump  could  be  felt  in  the  gall- 
bladder region.     On  opening  the  abdomen  a  second  time 
in  October,    1903,   the  gall-bladder  was  found  the  size 
of  a  small  hen's  egg,  full  of  solid  material.     On  incising  it 
the  swelling  w^as  found  to  be  new  growth  which  was  in- 
filtrating contiguous  parts  of  the  liver.     The  gall-bladder 
and  adjoining  part  of  the  liver  were  removed  successfully. 
Cases  such  as  these  strengthen  materially  the  plea  for 
cholecystectomy. 


326    Operations  on   Gall-bladder  and   Bile-ducts 

In  the  very  great  majority  of  operations  for  gall- 
stones there  is  ample  evidence  of  long-standing  in- 
flammation in  and  about  the  gall-bladder.  The  normal 
smoothness  of  the  gall-bladder  is  gone,  its  deep  blue 
colour  is  lost,  its  once  supple  walls  have  become  thickened 
and  tough.  A  glance  at  a  gall-bladder  during  other  ab- 
dominal operations  will  tell  one  in  a  moment  whether 
stones  are  lying  there.  If  the  gall-bladder  is  blue,  it  is 
healthy;  if  opaque  and  grey  or  yellow,  there  are,  or  there 
certainly  have  been,  stones  and  a  chronic  inflammation 
aroused  by  them. 

In  some  cases,  therefore,  it  will  be  conceded  that  chole- 
cystectomy is  the  more  desirable  operation,  but  before 
its  routine  adoption  is  advocated  it  is  necessary  to  shew 
that  the  gall-bladder  is  useless,  and  that  its  removal  does 
not  add  any  risk  as  compared  with  cholecystotomy.  In 
the  abstract,  one  might  be  inclined  to  think  that  the  loss 
of  a  bile  reservoir  capable  of  emptying  on  demand  would 
be  a  serious  matter  to  the  individual,  or  at  the  least,  a 
disabilit}'.  The  perfection  of  the  mechanism  of  digestion 
so  graphically  told  by  Pawlow  would  seem  to  require 
that  bile  should  be  ejected  in  spurts,  as  it  were,  into  the 
duodenum  during  digestion.  But  there  is  clinical  ex- 
perience in  abundance  to  shew  that  when  all  the  bile  is 
discharged  from  the  body  through  an  external  biliary 
fistula,  without  a  drop  entering  the  intestine,  the  in- 
dividual suffers  no  sign  of  disability  of  any  kind.  There 
is  abundant  evidence  also,  furnished  by  my  own  cases 
and  by  many  others,  to  shew  that  the  removal  of  the  gall- 
bladder does  not  interfere  with  digestion,  that  the  in- 
dividual eats  well,  gains  in  weight,  and  to  all  appearance 


Cholecystectomy  327 

has  the  same  duodenal  digestion  as  an  ordinary  healthy 
individual.  The  gall-bladder,  therefore,  if  not  useless, 
can  quite  well  be  spared. 

The  removal  of  the  gall-bladder  in  cases  judiciously 
selected  does  certainly  not  involve  a  greater  risk  than  the 
operation  of  cholecystotomy.  I  have,  in  fact,  in  several 
cases  been  convinced  that  the  removal  of  the  gall- 
bladder made  the  operation  simpler  and  shorter  than  it 
would  have  been  if  a  multitude  of  small  stones  had  been 
removed.  By  carrying  out  the  operation  in  the  manner 
described  below  it  will  be  found  a  safe,  speedy,  and  simple 
procedure.  During  the  last'  three  years  I  have  in- 
clined more  and  more  to  the  performance  of  cholecys- 
tectomy, and  after  some  hesitation  and  some  trepida- 
tion, which  experience  has  removed,  I  am  strongly  dis- 
posed to  advocate  the  frequent,  though  certainly  not  the 
invariable,  adoption  of  this  operation  in  preference  to 
cholecystotomy.  Its  advantages  are  that  the  operation 
removes  the  chief  source  of  the  disease,  that  it  thereby 
prevents  in  great  measure  a  recurrence  either  of  stones  or 
of  the  inflammation  which  betokens  their  presence,  that 
growths  in  the  gall-bladder  or  adhesions  around  it  are 
subsequently  impossible,  and  finally  that  the  wound,  if 
drainage  is  not  required,  may  be  caused  to  heal  through- 
out by  first  intention.  The  gall-bladder  is  devoid  of  any 
strikingly  useful  purpose,  and  its  removal  does  not  add 
appreciably  to  the  danger  of  the  operation.  If  drainage 
of  the  ducts  is  necessary,  it  can  be  carried  out  quite 
satisfactorily.  The  presence  of  a  stone  in  the  common 
duct  does  not  prohibit  the  operation,  but  drainage  of  the 
duct,  after  removal  of  the  stone  in  the  duct  or  in  the 
ampulla,  is  necessary. 


328    Operations  on  Gall-bladder  and  Bile-ducts 

The  one  disadvantage  that  may  justly  be  urged  against 
cholecystectomy  is  this:  that  if  a  late  operation  should 
become  necessary — for  stones  can,  and  do,  form  in  the 
hepatic  and  common  ducts — such  an  operation  would 
be  more  difficult  and  almost  certainly  more  dangerous. 
The  possibility  of  a  further  operation  being  necessary 
cannot  be  denied,  but  the  likelihood  of  it  is  negligible. 

Dr.  W.  J.  Mayo,  of  Rochester,  Minnesota  (Annals  of 
Surgery,  vol.  38,  p.  454),  gives  the  following  account  of 
his  opinion  with  regard  to  drainage  in  gall-stone  opera- 
tions : 

(i)  If  the  gall-bladder  contained  bile,  and  the  organ 
was  distensible,  if  the  gall-bladder  was  removed,  bile 
drainage  was  provided  for  by  cutting  the  cystic  duct 
across  and  leaving  it  open.  If  such  a  patient  was  very 
obese  or  had  degenerative  lesions  of  other  organs,  he 
preferred  cholecystotomy.  (2)  If  there  were  symptoms 
of  cholangitis,  even  of  mild  grade,  he  provided  for  bile 
drainage,  and  if  the  condition  was  acute,  the  drainage 
must  be  free.  (3)  If  the  gall-bladder  contained  cystic 
fluid,  but  no  bile,  and  the  patient  had  symptoms  of 
cholangitis,  he  removed  the  organ  and  cut  the  cystic 
duct  below  the  obstruction  to  permit  of  bile  discharge. 
If  necessary,  the  cystic  duct  was  split  down  to  the  common 
duct.  (4)  In  a  few  cases  he  had  directty  opened  the 
common  duct  for  the  purpose  of  securing  liver  drainage ; 
but  it  was  xevy  rare  that  this  was  necessary,  unless  there 
were  or  had  been  stones  in  the  common  duct,  and  it  was 
dilated.  The  cystic  duct  ordinarily  could  be  advantage- 
ously used  for  the  purpose ;  although  in  a  few  instances  he 
had  found  it  necessary  to  cut  it  off  flush  with  the  common 
duct,  leaving  a  lateral  defect  in  its  wall  for  drainage 
purposes.     This  brought  up  the  question  as  to  how  much 


Cholecystectomy  329 

danger  of  peritonitis  there  was  as  a  result  of  bile  leakage 
into  the  peritoneal  cavity.  If  there  was  free  gauze 
drainage,  with  or  without  tubage,  there  was  but  little 
danger  of  peritoneal  infection  from  the  bile.  He  had 
never  seen  a  case  of  death  from  this  cause ;  but  the  drain- 
age should  be  attached  to  the  proper  point  by  a  catgut 
suture  to  prevent  its  floating  away  by  the  bile  discharge 
or  displacement  by  the  action  of  the  diaphragm  upon  the 
liver.  If  the  common  duct  was  greatly  dilated,  and  after 
removal  of  the  calculi  there  was  considerable  detritus, 
the  end  of  a  rubber  drainage-tube  was  inserted  into  the 
duct  opening  and  secured  by  a  catgut  suture.  If  this 
condition  did  not  exist,  tubage  of  the  common  duct  was 
unnecessary. 

To  sum  up:  Cholecystectomy  was  to  be  preferred  if 
the  patient  was  otherwise  in  good  condition.  If  the 
cystic  duct  was  obstructed  and  the  gall-bladder  con- 
tained only  cystic  fluid,  ligation  of  the  cystic  duct,  without 
provision  for  hepatic  drainage,  was  safe.  If  there  was 
any  infection  of  the  hepatic  ducts,  bile  drainage  was 
essential. 

Dr.  Maurice  Richardson  (Med.  News,  May  2,  1903)  gives 
the  following  indications  for  extirpation  of  the  gall-blad- 
der: 

"  (i)  Certain  lesions  in  themselves  demand  removal 
of  the  gall-bladder  whenever  possible.  Such  are  new- 
growths  and  gangrenes.  (2)  Certain  other  lesions  of 
the  gall-bladder  are  better  treated  by  cholecystectomy. 
These  are  the  contracted  and  inflamed  gall-bladders, 
with  thickened  walls.  All  gall-bladders  which  do  not 
permit  easy  and  efficient  drainage  should  be  extirpated, 
for  in  such  gall-bladders  the  risks  of  drainage  are  quite  as 
great  as   the  risks   of  extirpation;    and   the   one  great 


330    Operations  on   Gall-bladder  and   Bile-ducts 

advantage  of  retention  is  impossible — retention  of  the 
biliary  reservoir  to  fulfil  the  functions  of  that  reservoir, 
and  to  permit,  if  necessary,  renewed  drainage  in  future 
years.  (3)  Drainage  is  preferable  in  the  dilated  and  in- 
fected gall-bladder,  which,  however,  is  neither  gangrenous 
nor  to  any  great  extent  changed — the  slightly  thickened 
gall-bladder  containing  gall-stones  and  infected  bile.  This 
gall-bladder  will,  after  drainage,  become  normal,  and, 
therefore,  capable  of  fulfilling  the  functions  of  a  gall- 
bladder. Through  it  the  biliary  passages  will  become 
effectually  drained,  after  subsidence  of  the  temporary 
swelling  about  the  cystic  duct.  (4)  As  a  rule,  drainage 
rather  than  extirpation  is  demanded  in  acute  cholecys- 
titis w4th  severe  constitutional  symptoms,  when  the  gall- 
bladder is  dilated,  or  at  least  not  contracted,  and  when  it 
is  not  gangrenous.  (5)  In  chronic  cholecystitis,  with 
dilatation  and  thickening  of  the  gall-bladder,  especially 
when  a  stone  is  impacted  in  the  cystic  duct,  extirpation 
is  the  preferable  operation,  unless  the  stone  can  be  dis- 
lodged backwards  into  the  gall-bladder,  in  which  case 
drainage  is,  if  not  preferable,  quite  as  advantageous  as 
extirpation.  (6)  In  simple  gall-stones,  without  visible 
evidence  of  infection  or  chronic  changes  incornpatible 
with  restoration  of  function,  simple  drainage  of  the  gall- 
bladder is  indicated.  (7)  In  chronic  pancreatitis,  whether 
associated  with  gall-stones  or  not,  drainage  through  the 
gall-bladder  is  indicated.  Cholecystectomy  is  unjustifi- 
able, for  immediate  drainage  is  essential.  Furthermore, 
reopening  of  the  biliary  passages  may,  in  the  future,  be 
required." 

The  Operation. —  Cholecystectomy  was  first  performed 
by  Langenbuch  on  July  15,  1882. 

The  operation  is  performed  in  the  following  manner: 
Mayo  Robson's  incision  is  made,  the  abdomen  opened,  the 


Cholecystectomy  331 

adhesions  separated,  and  the  Hver  rotated  in  the  manner 
already  described.  The  gall-bladder  may  be  remot-ed 
from  before  backwards,  or  from  behind  forwards;  that 
is  to  say,  the  cystic  artery  and  duct  may  be  first  cut 
across  and  the  gall-bladder  stripped  up  towards  the 
fundus,  or  the  peritoneum  around  the  fundus  may  be  first 
divided  and  the  gall-bladder  stripped  up  towards  the 
cystic  duct.  I  have  adopted  both  methods,  but  prefer 
the  former,  as  the  only  difficult  part  of  the  operation,  the 
ligature  of  the  pedicle,  is  accomplished  first. 

The  liver  being  held  upwards,  the  cystic  duct  and  its 
termination  in  the  common  duct  are  defined.  A  circular 
peritoneal  incision  is  now  made  around  the  cystic  duct 
about  half  an  inch  from  its  termination,  and  a  peritoneal 
cuff  is  stripped  up  towards  the  common  duct.  In  this 
way  the  cystic  duct  is  cleared  to  the  view.  Two  clips 
with  a  curved  beak  are  now  placed  on  the  cystic  duct,  and 
the  duct  is  divided  between  them.  The  clip  on  the 
gall-bladder  side  prevents  any  leakage  during  the  further 
steps  of  the  operation.  The  stump  of  the  cystic  duct  is 
ligatured  with  catgut,  and  the  clip  on  its  divided  end  is 
removed.  The  frayed  end  of  the  duct  is  trimmed  away 
with  scissors.  The  cystic  artery  and  vein  are  now  de- 
fined. They  lie  above  and  to  the  inner  side  of  the  divided 
duct,  and  may  be  readily  seen  by  gently  stripping  with 
gauze  that  part  of  the  pedicle  which  remains.  Two  clips 
are  applied  and  the  vessels  are  divided  between  them. 
The  proximal  end  of  the  vessels  is  now  ligatured  with 
catgut  and  the  clip  which  secures  them  is  removed. 
Occasionally,  another  vessel  than  the  cystic  artery  may 
need  to  be  clipped  and  Hgatured ;  it  is  a  separate  branch 


332    Operations  on  Gall-bladder  and  Bile-ducts 

of  the  hepatic  which  passes  to  the  common  and  cystic 
ducts.  If  there  is  no  inflammation  of  the  common  duct, 
and  if,  therefore,  there  is  no  need  for  drainage,  the  stump 
of  the  cystic  duct  may  be  covered  completely  by  its 
peritoneal  cuff,  which  is  fixed  over  it  by  one  or  two 
sutures  of  fine  Pagenstecher  thread.  A  small  flat  swab 
is  then  placed  over  the  common  duct,  and  the  separation 
of  the  gall-bladder  from  its  fossa  is  begun.  This  is  most 
easily  and  expeditiously  effected  by  working  upwards 
towards  the  fundus  with  the  index  finger,  which  is  in- 
sinuated at  first  between  the  pelvis  of  the  gall-bladder 
and  the  liver.  The  finger  may  be  covered  with  gauze 
so  as  to  make  the  separation  easier.  A  little  patience 
will  soon  secure  that  the  gall-bladder  is  stripped  cleanly 
away,  and  is  left  attached  only  by  a  peritoneal  fold 
around  it.  This  fold  is  then  divided  about  one-half  to 
three-fourths  of  an  inch  away  from  the  liver,  and  the 
gall-bladder  then  comes  away.  A  raw  surface  fringed 
by  a  collar  of  loosely  hanging  peritoneum  is  now  left. 
From  this  raw  surface  there  may  be  some  oozing.  This 
is  checked  by  the  pressure  of  a  swab  wrung  out  of  hot 
sterile  salt  solution.  Rarely  a  suture  may  be  necessary 
if  any  vessel  bleeds.  This  is  passed  with  a  curved 
intestinal  needle  and  tied  gently.  "When  all  the  oozing 
has  stopped,  the  peritoneum  around  the  denuded  surface 
is  closed  over  it  by  a  continuous  suture  of  catgut  which 
passes  from  the  liver  edge  to  the  cystic  duct.  A  final 
cleansing  of  the  operative  area  is  needed  and  the  abdomen 
may  then  be  closed. 

If,  however,  drainage  of  the  common  duct  is  necessary, 
it  may  be  secured  in  one  of  two  ways,  either  immediately 


Cholecystectomy  2>33 

or  after  the  lapse  of  a  few  days.  If  immediate  drainage 
is  desired,  the  cystic  duct  is  not  ligatured  in  the  manner 
described.  When  that  stage  in  the  operation  is  reached, 
the  clip  is  removed  from  the  stump  of  the  cystic  duct, 
and  the  cut  edges  are  seized  with  fine  French  vulsella. 
The  duct  is  slit  up  and  an  opening  is  made  into  it  at 
its  junction  with  the  hepatic  duct,  of  sufficient  size  to 
permit  of  the  introduction  of  a  rubber  tube.  This  is 
fixed  in  the  duct  by  a  suture  of  catgut  which  picks  up 
the  wall  of  the  common  duct  a  little  distance  away  from 
the  cut  edge.  To  the  outer  side  of  this  tube  a  second  one, 
which  is  split  and  has  a  gauze  wick,  passes  backward  into 
the  kidney  pouch.  This  second  tube  may  come  through 
the  abdominal  wound  or  be  made  to  project  from  a  stab- 
wound  in  the  loin,  preferably  the  former.  If  it  is  thought 
desirable  to  postpone  the  drainage  for  a  few  days,  the 
following  plan  which  I  have  found  convenient  may  be 
adopted.  The  clip  on  the  cystic  duct  is  removed  and  a 
small  clip  placed  so  that  the  open  end  of  the  duct  is  just 
seized.  Around  this  a  single  thin  catgut  ligature  is 
placed.  The  peritoneum  is  not  stitched  over  the  stump 
of  the  duct.  A  rubber  tube  is  now  passed  down  to  the 
ligatured  duct,  and  it  may  be  fixed  by  passing  a  stitch 
through  it  and  through  the  peritoneal  cuff.  The  perito- 
neum is  not  sutured  over  the  divided  end  of  the  duct.  The 
catgut  ligature  which  closes  the  duct  soon  gives  way,  in 
three  or  four  days,  and  bile  then  begins  to  flow  through 
the  tube.  By  this  time  an  impermeable  rampart  of 
adhesions  will  have  formed  around  the  tube,  and  will 
effectually  prevent  any  leakage  into  the  general  peritoneal 
cavitv. 


334    Operations  on   Gall-bladder  and   Bile-ducts 

Drainage  may  or  may  not  be  necessary  after  cholecys- 
tectomy. If  cholangitis  be  present,  as  in  those  cases 
where  a  stone  is  also  removed  from  the  common  duct  or 
from  the  ampulla,  it  is  certainly  necessary.  If,  however, 
the  inflammatory  changes  are  limited  to  the  gall-bladder, 
drainage  need  not  be  provided,  the  whole  abdominal 
wound  beins:  soundlv  closed. 


LUMBAR   CHOLECYSTOTOMY   OR    CHOLECYSTECTOMY. 

In  a  certain  small  proportion  of  cases  the  opening  or 
the  removal  of  the  gall-bladder  in  the  loin  may  be  deemed 
necessary,  as,  for  example,  when  a  mistaken  diagnosis 
of  renal  tumour  has  been  made  and  the  gall-bladder  has 
been  exposed.  W.  P.  Manton  (Amer.  Med.,  Oct.  4, 
1902)  describes  a  case  of  extirpation  of  the  gall-bladder 
through  a  lumbar  incision.  The  diagnosis  in  this  case 
was  nephroptosis  with  probable  cystic  metamorphosis 
of  the  kidney.  When  the  kidney  was  brought  out  of 
the  lumbar  wound  the  gall-bladder,  containing  a  num- 
ber of  stones,  could  be  easily  palpated,  and  was  so  thor- 
oughl}'  shut  off  from  the  general  peritoneal  cavity  either 
by  adhesions  or  because  of  its  anomalous  situation  that 
the  operator  was  able  to  remove  it,  with  the  cystic  duct, 
without  much  difficulty.  The  gall-bladder  and  the  cystic 
duct  contained  nineteen  stones. 


CHOLECYSTOTOMY  PERFORMED  UPON  THE  LEFT   SIDE. 

Carl  Beck  (Annals  of  Surgery,  vol.  29,  p.  593)  records 
a  case  of  cholecystotomy  in  which,  owing  to  transposition 


Hepatlcotomy  335 

of  the  viscera,  the  hver  lay  in  the  left  side  of  the  abdomen, 
and  the  incision  had,  therefore,  to  be  made  through  the 
left  rectus  muscle. 


THE   SURGERY   OF   THE   HEPATIC   DUCT. 

When  calculi  are  arrested  in  the  hepatic  duct,  they 
may  be  removed  through  incisions  made  into  the  gall- 
bladder, into  the  common  duct,  or,  rarely,  into  the  hepatic 
duct  itself,  or  they  may  be  crushed  and  the  fragments 
pressed  onwards  into  the  common  duct.  In  the  very 
great  majority  of  instances  stones  which  are  felt  in  the 
hepatic  ducts  can  be  milked  downwards  and  removed 
during  cholecystotomy  or  during  choledochotomy.  In 
very  exceptional  instances,  however,  the  performance  of 
hepaticotomy,  that  is,  incision  of  the  hepatic  duct,  may 
be  necessary. 

Hepatlcotomy. — The  operation  was  first  performed  by 
Kocher  on  Nov.  8,  1889,  unintentionally  and  unknow- 
ingly. In  the  hepatic  duct,  which  was  closely  adherent 
to  the  gall-bladder,  a  stone  was  tightly  wedged.  The 
duct  was  opened  and  the  stone  was  removed.  Shortly 
afterwards  the  abdomen  was  re-opened,  as  symptoms 
of  peritonitis  were  present.  Bile  was  found  in  the  general 
peritoneal  cavity.     The  patient  died. 

Other  operations  were  performed  by  Cabot  (1892), 
Elliot  (1894),  Czerny  two  cases,  Kehr,  and  recently 
Delageniere  and  Rogers.  Cabot's  case  was  one  in  which 
many  calculi  were  removed  from  the  gall-bladder.  A 
large  stone  was  then  felt  in  the  hepatic  duct  deep  under 
the  liver.     The  duct  was  opened  with  very  great  difticulty 


^;^6    Operations  on   Gall-bladder  and   Bile-ducts 

and  the  stone  extracted.     The  duct  and  the  gall-bladder 
were  drained  and  the  patient  recovered. 

Elliot  (Annals  of  Surgery,  vol.  22,  p.  86)  gives  the 
following  account  of  his  case: 

"  On  September  4  I  opened  the  abdomen  by  an  incision 
in  the  upper  right  linea  semilunaris.  The  gall-bladder 
was  found  empty  and  flaccid,  the  ducts  were  palpated, 
and  a  stone  was  felt  deep  under  the  liver  in  the  hepatic 
duct.  The  stone  could  not  be  pushed  along  the  duct 
nor  crushed  with  the  fingers.  Xo  other  stone  was  felt  in 
the  common  or  cystic  duct.  After  separating  numerous 
adhesions,  the  stone  was  seized  between  the  thumb  and 
forefinger  of  the  left  hand  and  pulled  up  from  its  deep 
position.  Adhesions  and  duodenum  were  pushed  aside 
until  the  stone  appeared  between  the  fingers  with  only 
the  peritoneum  and  the  wall  of  the  duct  covering  it. 
The  field  of  operation  was  packed  with  gauze  to  prevent 
contamination  with  bile,  the  duct  was  incised,  and  a 
stone  the  size  of  a  robin's  egg  extracted.  The  duct  was 
closed  at  once  with  catgut  sutures,  a  second  row^  of  silk 
sutures  including  the  peritoneum  being  placed  outside. 
The  duct  was  held  with  the  fingers,  and  very  little  bile 
escaped.  A  drainage-tube  and  gauze  were  packed  down 
to  the  sutured  duct.  A  rapid  and  complete  recovery 
followed.  The  duct  did  not  leak,  and  on  the  second  day 
the  gauze  drain  w^as  removed.  On  the  fourth  day  the 
abdominal  wound  was  completely  closed  by  provisional 
sutures.  The  jaundice  had  partially  disappeared,  and 
the  stools  were  natural  in  colour.  The  patient  was  well 
in  three  weeks.  Eight  months  after  operation  he  was 
known  to  be  in  perfect  health." 

In  Czerny's  case  and  in  one  of  Kehr's  the  duct  was 
ruptured  during  the  manipulations  attendant  upon  the 
removal  of  stones,  and  the  wound  was  closed  by  sutures. 


Hepatlcostomy 


J  J, 


An  interesting  case  of  hepaticotomy  is  related  by  Leonard 
Rogers.  A  full  account  of  it  is  given  in  the  chapter 
dealing  with  stone  in  the  hepatic  duct. 

The  operation  of  hepatlcostomy,  or  the  opening  of  the 
hepatic  duct  and  the  suture  of  the  duct  in  the  abdominal 
wound,  was  first  performed  by  Knowsley  Thornton  in 
1888.  He  removed  412  stones  from  a  dilated  hepatic 
duct  which  formed  a  swelling  closely  resembling  the  gall- 
bladder. The  duct  was  stitched  to  the  abdominal  wall 
and  drained.     The  fistula  closed  in  fourteen  days. 

A  remarkable  case  is  recorded  by  H.  V.  Chapman.  An 
abdominal  tumour  about  the  shape  and  size  of  a  large 
kidne}^  was  felt  in  the  abdomen ;  it  was  connected  with  the 
liver.  The  abdomen  was  opened  over  the  tumour  by  an 
incision  13  cm.  in  length  between  the  umbilicus  and  the 
anterior  superior  spine.  There  were  numerous  adhesions 
which  were  readily  freed.  The  tumour  was  seen  to  con- 
sist of  a  portion  of  the  liver  near  its  anterior  margin;  at 
the  lower  part  the  wall  was  thin  and  seemed  likely  to 
burst.  A  trocar  was  plunged  in,  and  480  c.c.  of  lightly 
bile-stained  fluid  were  withdrawn.  Then  with  a  round 
needle  the  tumour  was  stitched  to  the  abdominal  wall, 
and  a  few  days  later  was  opened  and  127  calculi  were 
removed  therefrom.  The  case  is  described  by  Pantaloni 
as  '^transhepatic  Jiepaticostoiny.'"  An  example  of  ''sub- 
hepatic Jiepaticostomy"  is  recorded  by  Xicolaysen  of  Kris- 
tiania.  The  patient  was  a  little  girl,  aged  eight,  in  whose 
abdomen  a  cyst  17  cm.  long  and  15  cm.  broad  was  felt. 
The  swelling  descended  about  three  fingerbreadths  below 
the  umbilicus.  A  year  before  there  had  been  jaundice 
for  three  months;    from  this  the  patient  recovered,  and 


338    Operations  on  Gall-bladder  and  Bile-ducts 

attended  school  to  within  three  days  of  her  admission  to 
hospital.  At  the  operation  the  cyst  was  fixed  to  the 
abdominal  wall,  and  six  days  later  was  aspirated.  Death 
occurred  on  the  following  day.  The  cyst  was  found  to  be 
formed  by  a  dilatation  of  the  whole  of  the  hepatic  and  of 
a  part  of  the  common  duct.  The  hepatic  duct  had  been 
stitched  to  the  abdominal  wound.  There  was  no  tumour, 
and  no  stone  could  be  found.  Xicolaysen  considered 
that  the  deformity  was  congenital  in  origin. 

Leonard  Rogers  (Brit.  Med.  Journ.,  vol.  2,  1903,  p. 
706)  records  a  case  in  which  the  hepatic  duct  was  opened 
under  the  impression  that  it  was  the  gall-bladder;  it 
was  brought  to  the  surface  and  drained.  The  patient 
died  the  next  day;  it  was  then  found  that  the  hepatic 
duct,  and  not  the  gall-bladder,  had  been  opened.  The 
duct  was  ■  immensely  dilated  behind  an  impacted  stone. 

Access  to  the  duct  may  be  readily  obtained,  as  was 
first  shewn  by  Elliot,  by  placing  a  sand-bag  under  the 
patient's  back  at  the  level  of  the  liver.  The  manoeuvre 
of  rotation  of  the  liver  already  described  makes  it  a  simple 
matter  to  expose  the  duct  to  view  and  to  easy  handling. 

The  operation  of  hepaticolithotripsy,  or  the  crushing 
of  a  stone  in  the  hepatic  duct,  is  at  times  the  safest  and 
the  speediest  method  of  dealing  with  such  an  obstruc- 
tion. It  was  first  suggested  by  Kocher  in  1890  and  has 
been  performed  by  ^layo  Robson,  Delageniere,  and  re- 
cently by  ^larcel  Baillet  (Bull,  et  Mem.  Soc.  de  Chir., 
vol.  29,  p.  1 194).  The  last  case  was  one  in  which  chole- 
dochotomy  and  suture  of  the  common  duct  had  been  per- 
formed. The  symptoms  were  not  relieved,  and  nine  days 
later  the  abdomen  was  re-opened  and  a  stone,  found 
in  the  hepatic  duct,  was  crushed.     The  result  was  good. 


CHAPTER  XI. 

OPERATIONS   FOR  OBSTRUCTION  OF  THE    COMMON 

DUCT. 

CHOLEDOCHOTOMY. 

A  stone  may  be  impacted  in  the  common  duct  in  anv 
point  of  its  course.  The  stone  may  be  soHtary,  or  there 
may  be,  and  commonly  are,  more  stones  than  one.  A 
stone  may  be  fixed  in  the  ampulla  and  a  second  stone, 
or  several,  may  be  wedged  in  the  upper  part  of  the  duct, 
or  even  in  the  hepatic  duct. 

Access  to  the  duct  may  be  obtained  in  three  positions, 
corresponding  to  the  three  divisions  of  the  duct  alreadv 
described. 

1.  As   the   duct   lies  in   the   free  edge  of  the  gastro- 

hepatic  omentum;    the  supraduodenal  portion. 

2.  As  the  duct  lies  behind  the  duodenum;  in  the  retro- 

duodenal  portion. 

3.  As  the  duct  lies  within  the  wall  of  the  duodenum; 

the  transduodenal  portion. 

The  operation  of  choledochotomy  consists  in  the  open- 
ing of  the  duct  in  any  of  these  three  positions. 

First. — Choledochotomy  performed  upon  the  first  por- 
tion of  the  common  duct.  The  operation  was  first 
suggested  by  Langenbuch  in  1884,  first  performed  by 
Kiimmell  in  the  same  year,  and  first  performed  success- 

339 


340  Operations  on  Common   Duct 

fully  by  Knowsley  Thornton  in  1889.  This  is  the  simplest 
operation,  and  in  my  experience  has  been  that  which  I 
have  been  most  frequently  called  upon  to  perform. 

The  position  of  the  patient  during  the  operation  is  a 
matter  of  great  importance.  All  the  steps  of  the  opera- 
tion, up  to  the  suture  of  the  abdominal  wound,  are  simpli- 
fied by  placing  a  large  sand-bag  under  the  patient's 
back  behind  the  liver,  as  already  described.  The  table 
may  be  slightly  tilted  so  that  the  feet  of  the  patient  are 
lowered  four  or  five  inches,  and  the  head  correspondingly 
raised.  Mayo  Robson's  incision  is  made, — that  is,  a 
vertical  incision  about  five  inches  in  length  near  the  outer 
border  of  the  rectus, — and  an  oblique  upward  and  in 
ward  prolongation  from  this  about  one-half  of  an  inch 
from  the  costal  margin  for  about  two  inches,  or  more  if 
necessary.  The  abdomen  is  opened,  the  kidney  and 
stomach  swabs  carefully  placed  in  position,  all  adhesions 
carefully  separated  by  gauze  stripping  or  divided  and 
ligatured,  the  bleeding  points  being  carefully  sought  and 
at  once  ligatured  in  this,  as  in  all  stages  of  the  operation. 

The  gall-bladder  and  the  edge  of  the  liver  are  now 
grasped  in  the  hand,  being  first  covered  by  gauze,  so  that 
a  firm  grip  may  be  obtained.  They  are  dragged  gently 
but  firmly  downwards  from  under  the  costal  margin, 
and  the  liver  is  then  rotated  so  that  the  posterior  surface 
of  the  gall-bladder  now  looks  forwards  and  upwards,  and 
the  common  duct  is  stretched  and  brought  much  nearer 
to  the  abdominal  wall.  In  thin  patients  the  common 
duct  is  brought  quite  on  a  level  with  the  skin  wound; 
in  fat  patients  this  is  not  possible,  but  in  all  the  duct  is 
made  easy  of  access.     It  is  possible  to  explore  it  thor- 


Choledochotomy  341 

oughly,  to  incise,  and  if  need  be  to  stitch,  it  without,  as 
a  rule,  any  difficulty. 

The  common  duct  now  being  exposed  is  surrounded 
A^ery  carefully  with  swabs  and  the  position  of  the  stone 
defined.  It  will  often  be  found  to  slip  about  in  the  dilated 
duct,  and  to  be  very  elusive.  This  is  from  some  points 
of  view  a  disadvantage,  but  it  often  enables  the  surgeon 
to  move  a  stone  impacted  low  down  in  the  duct  into  the 
upper  and  more  accessible  portion.  The  stone  is  now 
grasped  between  the  index  finger  and  thumb  of  the  left 
hand,  and  the  duct  incised  over  the  stone,  the  cut  being 
of  such  size  as  to  permit  the  easy  removal  of  the  stone. 
With  a  pair  of  forceps  or  with  a  gall-stone  scoop  the 
stone  is  now  dislodged.  Immediately  after  it  bile  will 
flow,  and  this  the  assistant  wipes  away  at  once,  before 
there  is  time  for  it  to  soil  the  parts  around.  Such  bile 
is  always,  or  almost  always,  infected  by  the  bacillus  coli 
communis,  if  not  by  other  organisms.  Any  other  visible 
stones  are  removed,  and  the  scoop  is  passed  upwards 
and  downwards  along  the  ducts  to  explore.  It  will 
always  be  found  that  the  duct  is  of  large  size,  partly  as 
the  result  of  an  old-standing  cholangitis,  partly  perhaps 
because  of  the  increased  tension  of  the  bile  therein.  The 
duct  will,  therefore,  be  large  enough  in  most  cases  to 
admit  the  finger — and  in  this  way  alone  can  a  perfectly 
satisfactory  exploration  of  the  duct  be  made.  A  stone 
that  will  evade  detection  by  the  scoop  is  at  once  per- 
ceived by  the  finger.  The  finger,  therefore,  should 
always  be  passed  both  upwards  and  downwards  along 
the  duct  and  a  free  exploration  made.  A  stone  even  in 
the  ampulla  may,  by  the  conjoined  manipulation  of  the 


342  Operations  on   Common   Duct 

fingers  on  the  duodenum  and  a  finger  within  the  duct,  be 
coaxed  upwards  into  the  duct  and  removed. 

This  digital  exploration  should  always  be  resorted 
to  in  common  duct  stone — but  it  must  be  remembered 
that  the  duct  is  a  septic  tract.  A  glove  finger  may, 
therefore,  be  put  on  before  the  exploration,  or  the  glove 
on  that  hand  may  be  changed.  After  the  duct  is  cleared 
of  stones  two  courses  are  open  to  the  surgeon :  he  may 
either  close  the  duct  by  suture,  or  he  may  drain  the  duct 
by  a  rubber  tube.  Each  case  must  be  decided  as  seems 
best,  but,  on  the  whole,  it  will  be  found  both  desirable 
and  necessary  to  drain. 

Drainage  of  the  common  duct  may  be  direct  or  in- 
direct— direct  when  a  tube  is  introduced  into  the  open- 
ing in  the  duct  made  for  the  extraction  of  the  stone, 
indirect  when  the  duct  is  sutured  and  a  drain  is  left  in 
the  gall-bladder,  or  in  the  stump  of  the  cystic  duct,  left 
after  removal  of  the  gall-bladder.  In  some  instances  one 
method,  in  other  instances  the  other,  may  seem  the  best. 
But  in  nearly  all  cases  drainage  by  one  or  other  of  these 
methods  is  imperative.  If  the  common  duct  is  closed 
by  suture  and  the  gall-bladder  drained,  it  is  prudent 
though  not  always  necessary  to  leave  in  the  wound  a 
wisp  of  gauze  whose  end  lies  against  the  sutured  line. 

If  drainage  is  employed,  a  rubber  tube  is  passed  up- 
wards towards  the  hepatic  duct  for  about  an  inch.  If 
the  opening  in  the  duct  is  very  w4de,  it  may  be  narrowed 
by  a  stitch  or  two  of  catgut,  introduced  by  Lembert's 
method.  The  tube  is  stitched  in  by  a  single  catgut 
suture,  which  picks  up  the  wall  of  the  common  duct  a 
little  outside  the  edge  and  passes  through  the  tube.     So 


Choledochotomy  343 

long  as  this  stitch  holds,  and  it  holds  about  seven  to  ten 
days,  the  tube  will  remain  in  place.  In  addition  to  this 
tube  another  drain  is  necessary  on  the  outer  side  of 
the  duct.  For  this  I  prefer  a  rubber  tube,  split  longi- 
tudinally, with  a  fine  gauze  wick.  The  tube  lies  to  the 
outer  side  of  the  duct  in  the  kidney  pouch;  it  may  be 
brought  out  of  the  abdominal  incision,  or  made  to  present 
in  a  stab  wound  in  the  loin,  preferably  the  former.  A 
third  tube  to  lie  to  the  inner  side  of  the  duct  is  occasionally 
necessary.  The  gauze  wick  projects  about  two  inches 
from  the  inner  end  of  these  tubes.  These  tubes  are  left 
in  from  three  to  ten  days,  as  seems  necessar\^  There  is 
no  advantage  in  removing  them  early. 

If  it  is.  deemed  prudent,  the  common  duct  may  be 
closed  by  suture.  This  is  done  by  a  continuous  stitch  of 
catgut  or  fine  celluloid  thread  taken  from  end  to  end  of 
the  incision  and  introduced  in  two  layers.  It  is  import- 
ant to  avoid  wounding  or  penetrating  the  mucosa,  as  any 
suture  which  gains  access  to  the  lumen  of  the  duct  may 
form  the  nucleus  of  a  calculus.  When  the  wound  is 
securely  closed,  a  split  rubber  tube  with  a  gauze  wick 
may  be  passed  down  to  the  duct,  as  a  matter  of  pre- 
caution in  the  unlikely  event  of  any  leakage  ensuing. 

There  does  not  seem  to  be  any  general  agreement 
among  surgeons  as  to  the  propriety  or  advisability  of 
adopting  drainage  after  the  removal  of  a  stone  from  the 
common  duct.  A  discussion  was  recently  held  at  the 
Societe  de  Chir.  de  Paris  (Bull,  et  Mem.  de  la  Soc.  de 
Chir.  de  Paris,  vol.  29,  p.  1194)  in  which  several  surgeons 
gave  their  experience.  Michaux  in  twelve  choledochot- 
omies  had   sutured  the  duct  in  all,  and  the  results  were 


344  Operations  on  Common   Duct 

"very  satisfactory."  A  drain  was  left  in  contact  with 
the  suture  line,  and  in  "  three  or  four"  there  was  a  slight 
escape  of  bile.  Quenu  had  abandoned  suture  entirely, 
as  second  operations,  owing  to  blockage  of  the  duct  by  the 
infolded  mucosa  or  blood  clot,  were  sometimes  called  for. 
Schwartz  considered  that  suture  of  the  duct  might  be 
responsible  for  certain  disasters,  and  he  advised  drainage 
in  all  cases.  Hartmann  considered  that  suture  of  the 
common  duct  was  "always  unnecessary,  and  sometimes 
harmful."  In  my  own  earh^  cases  I  not  infrequently 
stitched  the  wound  in  the  duct,  but  in  a  series  of  sixteen 
consecutive  cases  I  have  drained  the  duct  and  all  the 
patients  have  recovered. 

The  whole  operation  area  is  now  gently  wiped  with 
sterile  swabs  wrung  out  of  salt  solution,  and  the  li\-er  is 
replaced,  and  the  abdominal  wound  closed  in  part,  or 
wholly,  as  may  be  necessary. 

Second.  The  retroduodenal  portion  of  the  duct  may  be 
reached  from  behind  by  a  procedure  similar  to  that 
employed  by  Kocher  in  the  "  mobilising  of  the  duodenum  " 
as  a  preliminary  to  the  performance  of  gastro-duodenos- 
tomy.  This  method  was  suggested  at  the  German 
Surgical  Congress  in  1898  by  Haasler.  It  had  been  found 
necessary  three  times  in  eighteen  operations  for  stone 
in  the  common  duct.  Oscar  Block  of  Copenhagen  has 
described  a  similar  operation  to  this.  In  the  very  great 
majority  of  cases  a  stone  which  appears  to  be  fixed  in  this 
portion  of  the  duct  can  be  moved  upwards  into  the  first 
portion.  The  operation  to  be  now  described  is,  therefore, 
very  rarely  necessary. 

The  common  duct  is  exposed  in  the  manner  already 


Choledochotomy  345 

described.  The  parietal  peritoneum  of  the  posterior 
abdominal  wall  is  now  incised  vertically  about  one  and 
one-half  inches  to  the  right  of  the  duodenum.  The 
fingers  are  introduced  into  this  incision  and  the  peri- 
toneum stripped  up  until  the  duodenum  is  reached.  By 
dragging  gently  on  the  second  part  of  the  duodenum,  it 
can  be  turned  over  to  the  left  so  that  its  posterior  surface 
is  visible.  A  stone  seated  in  the  second  portion  of  the 
duct  can  now  be  felt,  and  the  duct  over  it  incised.  This 
part  of  the  duct  is  either  covered  by,  or  Hes  in,  a  groove 
within  the  pancreas.  The  gland  must,  therefore,  be  cut, 
or  be  separated  by  blunt  dissection.  In  Haasler's  three 
cases  the  former  procedure  was  once  necessary,  the  latter 
twice.  Vautrin  has  suggested  the  division  of  the  pan- 
creas by  means  of  the  thermocautery.  After  removal  of 
the  stone  the  duct  is  explored  and  sutured,  and  a  gauze 
drain  left  in  the  posterior  peritoneal  wound.  A  sound 
healing  of  the  duct  without  leakage  is  not  likely  to  occur, 
the  duct  being  here  devoid  of  any  peritoneal  investment. 
Third.  The  third  portion  of  the  duct  including  the 
ampulla  may  be  reached  by  what  is  known  as  diiodeno- 
choledochotomy .  The  duodenum  is  opened  and  the  ter- 
mination of  the  duct  in  its  second  portion  exposed, 
and  the  stone  or  stones  extracted  therefrom.  The 
operation  was  devised  and  first  practised  by  Dr.  Mc- 
Burney  of  New  York  in  1891.  The  earher  stages  of  the 
operation  are  those  which  have  already  been  described. 
The  stone  impacted  in  the  lower  end  of  the  duct  or  in  the 
ampulla  is  often  elusive,  being  recognised  only  after  close 
palpation,  and  shewing  a  tendency  to  slip  easily  away 
from    the    fingers    which    grasp    it.     The    duodenum    is 


346 


Operations  on   Common   Duct 


exposed,  and  if  deeply  placed  or  not  easily  accessible, 
it  may  be  freed  by  a  vertical  incision  in  the  peritoneum 
to  its  right  side,  as  already  described.  The  stone  is 
fixed  by  grasping  it  between  the  thumb  and  the  fingers 
of  the  left  hand.  The  duodenum  is  then  opened  by  a 
vertical  incision  about  one  inch  or  a  little  more  in  length. 
The  edges  of  this  incision  are  grasped  with  fine  vulsella 
and  held  apart.     The  greatest  care  is  taken  to  prevent 


Fig.  67. — The  duodenum  opened  to  shew  a  stone  projecting  thereinto 
from  the  common  duct. 


any  leakage  from  the  duodenum.  The  fluid  therein  is 
mopped  up  by  swabs,  which  are  at  once  thrown  away. 
As  a  rule,  the  ampulla,  with  the  stone,  is  seen  at  once,  and 
the  stone  may  even  be  visible  through  the  patent  orifice. 
If  so,  an  incision  is  straightway  made  through  the  mucosa, 
slitting  up  the  lower  end  of  the  duct,  and  the  stone  is 
lifted  out  with  a  scoop,  or  the  orifice  of  the  ampulla  may 
be  dilated  by  introducing  a  pair  of  forceps  and  widely 


Choledochotomy  347 

separating  the  blades  (Collins's  method).  If  there  is  any 
difficulty  in  locating  the  ampulla,  search  must  be  made 
for  the  longitudinal  fold,  which  is  generally  recognised 
without  difficulty.  If  the  stone  is  above  the  ampulla, 
the  lowest  part  of  the  duct  should  be  slit  up  from  the 
ampulla  and  a  scoop  introduced.  This,  with  the  aid  of 
the  finger  of  the  left  hand,  will  generally  dislodge  the  stone 
at  once.  The  clearance  of  the  duct  is  recognised  by  the 
immediate  flow  of  bile.  The  duct  should  then  be  ex- 
plored with  a  scoop  or  with  the  finger,  and  any  other 
stones  removed.  If  any  stones  are  felt  higher  in  the 
duct,  they  may  be  worked  downwards  by  means  of  the 
left  forefinger  and  middle  fingers  passed  through  the 
foramen  of  Winslow,  behind  the  supraduodenal  portion  of 
the  duct,  and  the  left  thumb  in  front  of  the  duct.  Be- 
tween the  fingers  and  the  thumb  the  duct  can  be  "  milked" 
and  any  stones  forced  downwards  into  the  duodenum. 
There  is  no  need  to  put  any  suture  in  the  opened  ampulla 
or  duct.  The  duct  lies,  at  this  point,  actually  in  the 
duodenal  wall,  and,  therefore,  there  is  no  risk  of  leakage. 
In  fact,  the  leaving  of  a  wide-mouthed  termination  to  the 
duct  probably  allows  of  free  drainage  of  the  duct  for 
some  period.  If,  however,  the  stone  lies  in  the  second 
portion  of  the  duct,  sutures  must  be  introduced  to  fix 
the  opened  duct  into  the  duodenum,  else  will  leakage 
occur,  and  bile  will  be  poured  into  the  peritoneal  cavity. 
The  duodenum  is  then  closed  by  a  double  row  of  sutures, 
the  first  taking  all  the  coats,  the  outer  one  only  the  serous 
coat.  The  strictest  cleanliness  is  observed  throughout 
the  operation,  and  any  soiling  from  the  duodenum  thereby 
prevented.  Drainage  of  the  abdominal  wound  is  not 
necessary. 


34^  Operations  on  Common   Duct 

It  will  be  seen  that  two  distinct  methods  of  removal  of 
stones  from  the  lower  end  of  the  common  duct  through 
the  duodenum  may  be  practised.  In  the  one,  the  am- 
pulla is  dilated  or  incised,  or  the  third  portion  of  the  duct 
divided,  and  the  stone  removed  therefrom;  in  the  other, 
the  lower  part  of  the  pancreatic  portion  of  the  duct  im- 
mediately above  the  ampulla  is  opened.  In  the  former, 
the  third  portion  of  the  duct  or  the  ampulla  is  opened; 
in  the  latter,  the  lower  part  of  the  second  portion  of  the 
duct. 

The  opening  of  the  ampulla  is  McBurney's  method. 
Since  the  duct  immediately  above  the  ampulla  lies  in  the 
wall  of  the  duodenum,  there  is  no  opening  up  of  any  space 
outside  the  duodenal  wall  by  an  incision  upon  a  stone 
lying  therein.  No  suture,  therefore,  is  necessarv;  the 
slitting  up  of  the  ampulla  merely  results  in  the  leaving  of 
a  wider  end  to  the  common  duct. 

The  opening  of  the  second  portion  of  the  duct  from  the 
duodenum  was  first  performed  by  Kocher  in  1894.  In 
this  operation  the  wall  of  the  duodenum  is  cut  completely 
through.  Immediately  outside  the  duodenum  lies  the 
overdilated  duct  containing  the  impacted  stone,  which 
causes  the  wall  of  the  duct  to  be  lightly  pressed  against 
the  duodenum.  A  part  of  the  pancreas  may  intervene, 
but  owing  to  the  encroachment  of  the  stone  upon  the 
duodenum,  it  has  probably  undergone  atrophy  from 
pressure,  and  has  become  fibrous  as  a  result  of  chronic 
inflammation.  In  the  majority  of  the  cases  recorded 
the  common  duct  seemed  to  lie  immediately  outside 
the  duodenum.  When  the  duct  has  been  opened  by 
this  route,  its  closure  mav  be  effected  bv  suture,  or  the 


Choledochotomy  349 

wall  of  the  duct  may  be  sutured  to  the  wall  of  the  duo- 
denum in  such  a  manner  as  to  ensure  the  formation  of  a 
choledocho-duodenal  fistula.  The  operation  was  indeed 
described  by  Kocher  under  the  term  choledocho-diio- 
denostomy.  During  the  manipulations  necessary  to  ex- 
pose the  duct  and  to  liberate  the  stone  the  duodenum, 
duct,  and  stone,  should  be  grasped  between  the  fingers 
and  thumb  of  the  left  hand,  in  order  to  prevent  the  elusive 
calculus  from  suddenly  slipping  away. 

After  the  stone  is  removed,  by  forceps  or  by  a  gall-stone 
scoop,  bile  w411  flow  freely  from  the  opened  duct.  The 
scoop  should  be  passed  upwards  and  the  whole  duct 
carefully  explored,  in  order  to  see  if  other  stones  are 
present. 

After  the  completion  of  the  suture  line  posteriorly  the 
duodenum  is  closed,  and  the  abdominal  wound  dealt  with 
in  the  usual  manner. 

The  following  description  of  this  operation  is  given 
by  Kocher.      (Stiles'   translation    of    Fourth  Edition,  p. 

231-) 

The  operation  is  as  follows: 

The  stone  situated  behind  the  duodenum  is  fixed  with 
the  finger,  and  after  the  duodenum  has  been  opened, 
as  above  described,  at  a  point  opposite  to  the  stone,  an 
incision  is  made  down  on  to  the  stone.  Whether  the 
incision  should  be  transverse  or  longitudinal  will  be 
determined  by  the  position  and  shape  of  the  stone.  The 
distended  common  bile-duct  is  more  likely  to  be  found 
applied  to  the  duodenum  in  the  whole  length  of  the 
necessary  incision,  if  the  latter  be  made  in  the  long  axis  of 
the  stone.     In  this  case  also  we  advise,  as  does  Elliot, 


350  Operations  on  Common   Duct 

for  choledochotomy  in  general,  that  the  wall  of  the 
duodenum  and  bile-duct  right  down  to  the  stone  should  be 
seized  with  artery  forceps  as  soon  as  incised,  and,  if 
necessary,  a  stitch  may  be  passed  through  the  middle 
of  the  entire  thickness  of  both  eciges  of  the  wound,  so  as  to 
keep  up  the  apposition  of  the  two  walls  and  facilitate  a 
choledocho-duodenostomy.  as  we  have  termed  the  opera- 
tion, if  this  be  required.  After  the  stone  has  been  ex- 
tracted, the  canal  should  be  probed — with  the  finger  if 
possible — so  that  other  stones  may  not  be  overlooked. 
Whether  the  opening  is  now  closed  in  the  ideal  way  (by 
a  suture  through  the  whole  thickness  of  the  wound,  with 
a  secondary  suture  to  approximate  the  mucous  edges) 
or  not,  must  depend  upon  whether  the  opening  in  the 
papilla  is  stenosed  or  not.  As  a  general  rule,  it  will  be 
found  advantageous  to  make  sure  of  a  considerable  open- 
ing where  there  is  a  danger  of  the  formation  of  new  stones. 
If  the  opening  is  not  required,  it  will  contract  of  its  own 
accord.  A  suture  should,  therefore,  be  put  in  all  round 
the  opening  through  the  whole  thickness  of  both  canals. 
In  Kocher's  and  Kehr's  case,  in  which  this  method  was 
adopted,  no  bad  consequences  resulted  from  chance 
regurgitation  of  intestinal  contents. 

The  following  case,  in  which  Kocher's  operation  of 
choledocho-duodenostomy  was  performed,  is  related  by 
Thienhaus  (Annals  of  Surgery,  vol.  36,  p.  928): 

The  patient  was  a  woman  fifty-three  years  of  age  who 
had  complained  for  five  or  six  years  of  severe  attacks  of 
epigastric  pain.  For  twelve  months,  since  an  extremely 
acute  attack,  she  had  been  intensely  jaundiced,  and  had 
lost  during  that  time  102  pounds  in  weight.  From  the 
sudden  onset,  the  unvarying  jaundice,  and  the  absence  of 
swelling  of  the  gall-bladder  a  diagnosis  of  complete  ob- 


Choledochotomy  351 

struction  of  the  common  duct  was  made,  and  operation 
was  undertaken. 

"A  large  bag  was  put  under  the  hver  of  the  patient, 
and  then  the  abdomen  opened  by  a  longitucHnal  incision 
on  the  outer  border  of  the  rectus  muscle.  After  freeing 
some  adhesions  with  the  omentum,  the  gall-bladder  and 
a  part  of  the  cystic  duct  were  found  transformed  into 
a  rocky-like  mass  of  the  size  of  two  thumbs,  the  gall- 
bladder containing  not  a  drop  of  fluid.  After  a  large 
incision  into  the  thickened  wall  of  the  gall-bladder,  this 
mass,  which  appeared  to  consist  of  numerous  gall-stones 
welded  together,  was  dug  out,  and  a  gauze  sponge  put 
into  the  bladder  to  avoid  oozing  into  the  abdominal 
cavity  during  operation.  Then  a  transverse  incision 
through  the  rectus  muscle  and  the  suspensory  ligament 
of  the  liver  was  made  to  gain  better  access  to  the  region 
of  the  common  duct.  Putting  one  finger  into  the  fora- 
men of  Winslow,  and  the  thumb  of  the  same  hand  above 
the  common  duct,  the  choledochus  was  explored.  Three 
concretions  were  found  movable  in  this  duct,  and  besides 
that,  a  hard  mass  in  the  retroduodenal  portion  of  the  duct. 
As  several  manipulations  to  dislodge  this  concretion  into 
the  supraduodenal  portion  of  the  common  duct  proved 
futile,  the  duodenum  was  incised  by  a  longitudinal  in- 
cision on  the  anterior  wall.  Then,  as  I  could  not  find 
the  papilla  immediately,  an  incision  was  made  through 
the  posterior  wall  of  the  duodenum  and  choledochus  to 
this  immovable  concretion,  after  having  brought  the 
movable  stones  downward  to  the  impacted  stone,  holding 
them  tightly  in  this  position  by  the  index  finger  of  the 
left  hand  introduced  into  the  foramen  of  Winslow,  and 
the  thumb  of  the  same  pressing  the  upper  portion  of  the 
common  duct. 

' '  With  some  difficulty  the  incarcerated  stone  was  dug 
out  of  its  diverticulum,  the  other  stones  were  easily 
stripped  into  the  duodenum,  the  duodenum  and  chole- 


352  Operations  on  Common   Duct 

dochus  sutured  together  with  four  silk  sutures  (chole- 
dochoduodenostomis  interna),  and  then  the  duodenum 
on  the  anterior  wall  closed  in  the  usual  manner.  The 
gall-bladder  was  drained  with  a  drainage-tube  after 
Poppert's  method,  and  a  strip  of  iodoform  gauze  put 
around  this  tube  and  down  to  the  suture  of  the  duo- 
denum. The  patient  made  an  uneventful  recovery; 
her  pulse  and  temperature  were  never  over  loo ;  the  fistula 
from  the  gall-bladder  closed  by  itself  five  weeks  after  the 
operation.  She  left  the  hospital  six  weeks  after  opera- 
tion, her  weight  increasing  rapidly  (thirty-seven  pounds 
in  four  and  one-half  months)." 


During  the  performance  of  operations  for  gall-stones 
it  may  be  difficult,  it  is,  indeed,  at  times  impossible,  to  say 
whether  a  stone  is  present  in  the  common  duct.  An 
enlarged  lymphatic  gland  lying  in  the  free  edge  of  the 
gastro-hepatic  omentum  may  be  absolutely  indistin- 
guishable by  touch  alone  from  a  calculus  in  the  first 
portion  of  the  common  duct.  It  causes  a  hard,  rounded, 
slightly  mobile  swelling,  in  all  respects  similar  to  a  stone. 
When,  however,  the  method  of  rotation  of  the  liver  is 
employed  and  the  duct  is  brought  to  the  surface,  the 
distinction  between  the  tw^o  is  readily  made. 

It  is  not  so  much  in  this  first  part  of  the  duct  that 
difficulties  are  likely  to  occur.  It  is  in  the  second  and 
third  portions  of  the  duct  when  a  stone  is  present  it  may, 
indeed,  often  is,  surrounded  by  a  dense  thickening  in  the 
head  of  the  pancreas  so  that  in  the  midst  of  this  tough 
mass  no  definite  stone  can  be  felt.  Or,  on  the  other  hand, 
so  dense  and  resistant  a  swelling  may  there  be  felt  that 
the  surgeon  may  have  no  doubt  that  a  stone  will  be  found. 


Choleclochotomy  353 

Yet  on  cutting  into  the  swelling,  or  on  introducing  a 
finger  into  the  duct,  no  calculus  is  felt.  In  some  in- 
stances a  small  chronic  abscess  in  the  head  of  the  pan- 
creas may  be  opened.  Legueu,  Schwartz,  and  others  have 
recorded  cases  of  localised  induration  of  the  head  of  the 
pancreas,  incised  in  the  belief  that  a  stone  was  present, 
and  until  I  became  familiar  with  the  conditions  of  chronic 
pancreatitis  I  made  several  such  mistakes. 

When  a  stone  is  impacted  in  the  ampulla  of  Vater, 
it  may  be  so  small  as  to  be  felt  with  difficulty,  or  being 
felt  it  may  be  mistaken  for  a  hard,  inflammatory,  or 
perhaps  malignant  nodule  in  the  pancreas.  A  growth  in 
the  ampulla  cannot  be  discriminated  from  stone  until  the 
duodenum  is  opened.  In  the  only  case  of  carcinoma  of 
the  ampulla  that  I  have  seen  it  was  thought  that  the 
small,  hard,  rounded  lumpw'as  calculous,  and  it  was  only 
after  slitting  up  the  ampulla  that  a  growth  therein  was 
disclosed. .  Difficulties,  therefore,  in  the  recognition  and 
discrimination  of  stone  in  the  lower  end  of  the  duct  may 
arise  from  (a)  stones  being  overlooked,  a  thickening  felt 
involving  the  duct  and  its  surroundings  being  looked  upon 
as  due  to  inflammatory  deposit,  (b)  No  abnormality 
being  recognised  when  a  postmortem  examination  or  a 
later  operation  discloses  the  presence  of  a  stone,  (c) 
A  condition  supposedly  due  to  calculus  being  recognised 
and  the  duct  being  directly  incised,  or  the  ampulla  laid 
open  and  the  duct  probed,  with  the  result  that  no  ob- 
struction is  found. 


23 


354  Operations  on   Common   Duct 

LUMBAR  CHOLEDOCHOTOMY. 

Access  to  the  common  duct  may  also  be  obtained  by 
the  lumbar  route,  as  was  shewn  by  Braun  in  1876.  On 
one  occasion  Tuffier  has  performed  liunbar  choledoclwtoniy 
successfully.  The  method,  however,  as  a  deliberate 
procedure  possesses  no  conceivable  advantages,  and 
may  usefully  be  relegated  to  oblivion. 

Though  these  operations  are  described  separately  for 
convenience,  it  must  not  be  considered  that  they  are 
performed  in  the  academic  method  here  portrayed.  In 
several  instances  I  have  simultaneously  performed  cho- 
ledochotomy  and  cholecystotomy,  choledochotomy  and 
cholecystectomy,  and  duodeno-choledochotomy  and  chole- 
cystotomy or  cholecystectomy.  One  point  cannot  be 
too  frequently  nor  too  strenuously  emphasised,  that  is, 
that  drainage  is  the  secret  of  success  in  gall-bladder 
surgery;  it  is  always  an  advantage,  often  imperative. 
In  cases  of  cholangitis,  as  made  manifest  by  fever  or 
jaundice  or  both,  and  of  pancreatitis,  drainage  must  be 
practised,  and  should  be  maintained  for  a  considerable 
time. 


OPERATIONS  FOR  IMPERMEABLE  OR  IRREMOVABLE 
OBSTRUCTION  OF  THE  COMMON  DUCT. 

When  the  common  duct  is  occluded  by  stricture,  or 
growth,  or  rarely  by  inaccessible  or  irremovable  calculus 
(if  indeed  such  a  thing  exists),  it  may  be  necessary  to 
divert  the  stream  of  bile  by  forming  a  communication 
between  the  gall-bladder  or  the  duct  above  the  obstruc- 


Cholecystenterostomy  355 

tion  and  some  part  of  the  alimentary  canal.  Anastomoses 
have  been  made  between  the  gall-bladder  and  the  stomach, 
cholecystgastrostomy ;  with  the  duodenum  or  any  part 
of  the  small  intestine,  cholecystenterostomy;  or  with  the 
colon,  cholecystcolostomy.  The  common  duct  has  been 
united  to  the  duodenum  or  other  accessible  part  of  the 
small  intestine,  choledocho-enterostomy.  The  duodenum 
is  the  portion  of  the  bowel  selected  whenever  possible, 
but  where  adhesions  are  binding  and  inseparable,  any 
accessible  portion  of  the  stomach  or  small  or  large  intes- 
tine may  be  chosen.  These  operations  are  rarely  prac- 
tised at  the  present  time.  Since  the  longer  incisions 
have  been  made  and  the  method  of  rotation  of  the  liver 
already  described  has  been  practised,  the  common  duct 
has  been  more  readily  accessible,  and  any  obstruction  has 
been  more  easily  overcome.  There  are  very  few  indi- 
cations for  the  operations. 


CHOLECYSTENTEROSTOMY. 

The  operation  of  cholecystenterostomy  was  suggested 
by  Nussbaum  and  first  performed  by  v.  Winiwarter  in  an 
operation  which  was  performed  in  six  stages  on  dates 
from  July  20,  1880,  to  November  14,  1881. 

It  has  been  generally  agreed  that  for  the  purpose  of 
effecting  the  anastomosis  a  Murphy's  button  should  be 
used,  and  if  any  mechanical  appliance  is  necessary,  cer- 
tainly none  is  so  good  as  this.  In  one  case,  however, 
Mayo  Robson  has  found  the  anastomotic  opening  made 
in  this  way  narrowed  almost  to  obliteration.  I  have  only 
once  been  called  upon  to  perform  the  operation,  in   a 


;56 


Operations  on  Common   Duct 


case  of  chronic  pancreatitis  (drainage  of  the  gall-bladder 
is  the  better  operation  in  this  condition).  I  then  adopted 
the  method  of  simple  suture,  the  stitches  being  passed  in 
exactly  the  same  manner  as  in  the  operation  of  gastro- 
enterostomy.    The  advantage  of  simple  suture  is  that  the 


Fig.  68. — a,  Cholecystenterostoniy  combined  with  exclusion  of 
the  intestine  and  end-to-end  anastomosis,  a  method  I  have  once 
adopted;  b,  cholecystenterostomy  combined  with  entero-anastomosis 
as  suggested  by  von  MikuUcz  and  Maragliano. 


opening  may  be  made  of  ample  size,  so  that  subsequent 
narrowing  or  closure  need  not  be  feared.  If  possible, 
enough  of  the  gall-bladder  and  of  the  duodenum  should 
be  drawn  up  into  the  wound  to  allow  of  the  application  of 
small  intestinal  clamps.  These  will  facilitate  the  opera- 
tion considerably  by  keeping  the  ^'iscera  to  be  sutured 


Cholecystenterostomy  357 

close  together  without  difficulty,  and  by  preventing 
any  leakage  from  the  openings.  The  two  portions  to  be 
anastomosed  lying  side  by  side,  a  continuous  suture  of 
fine  Pagenstecher  thread  is  now  introduced  along  a  line 
at  least  one  inch  in  length.  This  suture  picks  up  only 
the  peritoneal  and  subperitoneal  coats.  In  front  of 
this  line  of  stitches  an  incision  is  now  made  into  the  gall- 
bladder and  into  the  intestine,  the  length  being  about 
three-fourths  of  an  inch.  The  edges  of  these  incisions 
are  now  united  by  a  continuous  suture  of  catgut  which 
begins  at  the  one  end  of  the  incision,  unites  the  posterior 
edges  of  the  wounds  until  the  opposite  end  is  reached,  and 
then  returns  along  the  anterior  edges  until  the  starting- 
point  is  reached.  The  suture  is  a  continuous  one,  and 
unites  the  edges  by  a  through-and- through  stitch.  The 
ends  of  this  suture  are  cut  short,  and  the  first  needle 
w^hich  has  been  temporarily  laid  aside  is  now  resumed 
and  the  serous  coat  united  along  the  anterior  m.argin  of 
the  wound,  to  the  point  whence  it  started.  Thus  there 
are  two  continuous  sutures  which  completely  surround 
the  opening:  an  inner  one  of  catgut  which  picks  up  all 
the  coats  of  each  viscus,  and  an  outer  one  of  Pagenstecher 
thread  which  unites  only  the  serous  and  subserous  coats. 
If  the  duodenum  is  not  accessible,  the  stomach  may  be 
chosen.  The  records  of  seven  cases  of  cholecystgastros- 
tomy  were  collected  by  Perier  in  1902.  Of  these,  six 
proved  successful.  The  fact  that  bile  is  not  injurious 
to  the  stomach  and  does  not  in  any  way  interfere  with 
digestion  has  been  shewn  by  a  case  of  my  own  recorded 
in  the  British  Medical  Journal  (vol.  i,  1901,  p.  1136) 
and  by  the  experiments  of  Stendel  upon  dogs. 


358  Operations  on   Common   Duct 

If  the  small  intestine  is  selected  for  the  anastomosis, 
some  difficulty  may  result  from  the  passage  of  the  intes- 
tinal contents  into  the  gall-bladder.  To  overcome  this 
difficulty  the  operation  may  be  performed  after  the 
method  suggested  by  Mikulicz.  A  loop  of  the  intestine 
is  isolated.  The  apex  of  the  loop  is  united  to  the  gall- 
bladder ;  the  sides  of  the  loop,  about  four  inches  away, 
are  united  to  each  other  by  a  lateral  anastomosis.  The 
intestinal  contents  are  in  this  way  short-circuited  and 
there  is  no  risk  of  infection  of  the  gall-bladder  from  the 
intestine. 

It  would,  doubtless,  be  an  advantage  in  cases  such  as 
this  to  perform  intestinal  exclusion,  as  well  as  cholecyst- 
enterostomy.  The  small  intestine  at  the  point  selected 
would  then  be  divided  completely,  the  proximal  end 
would  be  united  to  the  side  of  the  distal  end,  about  five 
inches  from  the  point  of  division,  and  the  distal  end  would 
be  closed,  or  a  lateral  anastomosis  made  with  the  fundus 
of  the  gall-bladder.     I  have  operated  thus  in  one  case. 


CHOLEDOCHOSTOM  Y. 

The  operation  of  choledochostomy,  the  opening  of  the 
common  duct  and  the  suture  of  the  margins  of  the  open- 
ing to  the  abdominal  wound,  is  said  to  have  been  first  per- 
formed by  Parkes.  This,  however,  is  incorrect.  It  was 
drainage  of  the  duct  that  Parkes  adopted,  the  perform- 
ance of  choledochotomy  without  sutures.  The  opera- 
tion of  choledochostomy  was  first  performed  by  Helferich 
in  1887,  subsequently  by  Ahlfeld,  v.  Winiwarter,  and 
others.     The   nature   of  the   operation   in   the   cases   of 


Choledochostomy  359 

Helferich  and  Ahlfeld  was  only  recognised  at  autopsy; 
it  was  believed  in  both  that  the  distended  gall-bladder 
w^as  being  opened.  To  v.  Winiwarter  belongs  the  credit 
of  first  deliberately  performing  the  operation  knowing 
what  he  did.  In  all  the  cases  recorded  the  common  duct 
has  been  greatly,  often  enormously,  dilated  behind  an 
obstructing  calculus.  That  the  dilatation  must  be  con- 
siderable is  recognised  when  we  know  that  in  two  cases 
mentioned  and  in  several  others  the  duct  has  been  mis- 
taken for  the  gall-bladder,  or  even  for  a  pancreatic  cyst. 
Several  remarkable  examples  of  extreme  dilatation  of  the 
common  duct  have  already  been  mentioned.  The  duct 
may  be  opened,  emptied,  and  forthwith  stitched  to  the 
parietal  peritoneum  and  the  aponeurosis,  or  the  operation 
may  be  done  in  two  stages,  the  opening  of  the  cyst  being 
deferred  until  union  between  the  duct  and  the  peritoneum 
is  complete. 

In  Helferich's  case  the  biliary  fistula  bled  and  sup- 
purated, and  the  patient  died  about  one  month  after  the 
operation.  Ahlfeld's  patient  died  on  the  eighth  day  of  col- 
lapse. Von  Winiwarter's  patient  died  six  weeks  after  the 
operation,  of  gradual  exhaustion  due  to  the  generalisation 
of  a  malignant  growth.  The  following  case  is  worthy  of 
record  as  shewing  the  conditions  likely  to  be  met  with 
during  operation. 

It  is  recorded  by  Hamilton  Russell  (Annals  of  Surgery, 
vol.  26,  1897,  p.  692) : 

George  S.,  aged  eight,  was  admitted  to  the  Mel- 
bourne Hospital  for  Sick  Children  March  23,  1897. 

On  the  1 8th,  five  days  previously,  he  became  feverish 


;6o 


Operations  on  Common   Duct 


and  ill,  and  on  the  next  day,  the  20th,  the  mother  noticed 
a  swelling  of  the  right  side  of  the  abdomen.  There  was 
constipation,  and  the  one  motion  passed  during  the  five 
days  prior  to  admission  was  putty-like  and  offensive; 
the  urine  was  deeply  coloured  with  bile. 

On  admission,  the  patient  was  a  well-nourished  child, 


Fig.  69. — Case  of  choledochostomy.  Under  surface  of  liver  with 
attached  organs:  a,  Gall-bladder  laid  open;  b,  cyst;  c,  duodenum 
laid  open;    d,    pancreas   (Hamilton   Russell). 


with  the  history  of  having  enjoyed  excellent  health  up  to 
the  onset  of  the  present  illness.  Jaundice  was  general  and 
marked;  temperature,  102°  F. ;  pulse,  128.  Examination 
of  the  abdomen  revealed  the  following:  The  right  flank 
was  occupied  by  a  large,  tense,  elastic  tumour,  dull  on 
percussion,  being  continuous  with  the  liver  dulness  above ; 


Choledochostomy  361 

extending  downward  an  inch  below  the  ihac  crest,  reach- 
ing inward  nearly  to  the  midline,  and  posteriorly  oc- 
cupying the  entire  lumbar  region.  There  appeared 
to  be  distinct  tenderness  on  palpation  of  the  tumour; 
there  was  a  slight  increase  of  the  liver  dulness  upward. 
A  second,  smaller  tumour  projected  visibly  immediately 
beneath  the  rib-cartilage,  about  the  right  linea  semilun- 
aris ;  this  tumour  was  rather  larger  than  a  pigeon's  egg, 
round,  soft,  elastic,  and  painless.  Both  heart  and  lung 
sounds  were  normal. 

The  view  taken  as  to  the  nature  of  the  case  was  as 
follows:  The  larger  tumour  was  believed  to  be  an 
echinococcus  cyst,  which  had  escaped  notice  until  the 
onset  of  the  present  illness;  the  smaller  tumour  was 
either  a  second  cyst  or  possibly  a  distended  gall-bladder. 

Operation  on  April  8th.  The  abdomen  was  opened  by  a 
four-inch  incision  in  the  right  linea  semilunaris,  extend- 
ing downward  from  near  the  costal  margin.  The  smaller 
tumour  at  once  presented,  and  was  found  to  be  the  gall- 
bladder distended  with  colourless  contents ;  there  were  no 
adhesions,  so  that  its  entire  contour  could  be  readily 
felt.  Turning  now  to  the  larger  cyst,  this  was  found  to 
be  retroperitoneal,  and  the  colon  was  bound  to  the  face  of 
it,  being  nearer  the  inner  than  the  outer  side  of  the  cyst. 
An  exploring  syringe  was  now  used,  and  perfectly  clear, 
limpid  fluid  obtained,  having  all  the  physical  appearance 
of  hydatid  fluid.  The  cyst  was  next  emptied  in  great 
part  by  aspiration  and  then  incised,  when  three  surprising 
discoveries  were  made :  (i)  in  the  fluid,  as  it  flowed,  there 
came  several  blackish  masses  looking  like  cinders;  (2) 
there  was  no  echinococcus  cyst ;  (3)  at  the  end  of  the  flow 
the  fluid  w^as  observed  to  suddenly  change  in  character, 
and  in  place  of  the  clear  limpid  fluid  there  came  one  or  two 
ounces  of  less  clear  and  distinctly  mucinous  fluid.  It 
was  now  ascertained  that  this  mucinous  fluid  had  come 
from    the    gall-bladder,    which    was    collapsed,    having 


362 


Operations  on   Common   Duct 


emptied  into  the  larger  cyst.  Thus  it  was  evident  that 
this  large  retroperitoneal  cyst  had  a  communication  with 
the  common  bile-duct,  and  the  only  conclusion  I  was  able 
to  arrive  at  as  the  result  of  much  speculation,  with  which 
I  need  not  weary  the  reader,  ascribed  to  the  cyst  a 
pancreatic  origin ;  the  possibility  did  not  occur  to  me  that 
in  a  child  of  eight,  who  had  never  suffered  a  day's  illness 
until  three  weeks  previously,  this  enormous  cyst  could 
itself  be  the  dilated  common  bile-duct. 


Fig.    70. — Ahlfeld's   case  of   choledochostomy:   a.  The    dilated    duct 
stitched  to  the  skin. 


The  operation  was  completed  by  stitching  the  opening 
in  the  cyst  to  the  musculature  of  the  abdominal  wall,  and 
closing  the  abdominal  wound.  After  the  operation  the 
whole  of  the  bile  commenced  to  flow  from  the  opening; 
with  the  view  of  ascertaining  whether  there  was  any 
admixture  of  pancreatic  fluid  with  the  bile,  its  digestive 
properties  were  investigated  by  my  colleague,  Dr.  Sta- 
well,  with  a  negative  result,  nor  was  any  excess  of  fat 
discovered  in  the  stools.     The  child  died  four  days  after 


Choledochostomy  363 

the  operation,   from  haemorrhage,   the  result  of  uncon- 
trollable oozing  from  the  stitches  and  into  the  cyst. 

Autopsy.  The  body  was  universally  jaundiced,  and 
had  the  waxen  appearance  characteristic  of  death  from 
haemorrhage;  the  cyst  was  filled  by  a  mass  of  normally 
clotted  blood,  with  some  bile.  On  opening  the  body  the 
intestines  appeared  to  be  lightly  smeared  with  blood, 
and  the  points  of  contact  of  neighbouring  coils  were 
marked  by  lines  of  blood;  all  the  organs  were  healthy 
with  the  exception  of  those  concerned  in  the  operation. 
The  liver  with  the  system  of  biliary  vessels,  including  the 
cyst,  the  duodenum,  pancreas,  and  spleen,  were  removed 
in  one  piece  and  are  portrayed  in  the  accompanying  il- 
lustration. The  cyst  is  seen  to  communicate  anteriorly 
with  the  gall-bladder,  the  cystic  duct  being  dilated  so  as 
easily  to  admit  an  ordinary  penholder.  At  the  transverse 
fissure  the  dilated  hepatic  ducts  are  seen  opening  into  the 
cyst.  The  duodenum  and  the  head  of  the  pancreas  are 
spread  over  the  outside  of  the  cyst.  A  careful  search  for 
the  terminal  portion  of  the  common  bile-duct  reveals  a 
small  valvular  opening  on  the  interior  of  the  cyst  through 
which  a  probe  can  be  passed  into  the  duodenum,  on  the 
surface  of  which  it  appears  through  the  usual  papilla; 
that  this  is  the  normal  termination  of  the  common  bile- 
duct  is  proved  by  passing  a  second  probe  through  the 
same  duodenal  orifice  into  the  pancreatic  duct;  this  can 
be  easily  done.  Russell  adds,  "We  may  safely  conclude 
that  the  condition  was  congenital." 

Additional  cases  are  recorded  by  Edgeworth  and  others. 
See  chapter  on  "The  General  Patholog}^  of  Gall-stone 
Diseases." 


364  Operations  on  Common  Duct 

CHOLEDOCHO-ENTEROSTOMY. 

If  the  nature  of  the  cyst  formed  by  the  dilatation  of 
the  common  duct  can  be  recognised,  it  is  certainly  better 
to  perform  an  anastomosis  between  the  overdilated  duct 
and  the  intestine.  This  operation,  choledocho-enter- 
ostomy,  was  first  performed  by  Riedel  in  1888.  It  was 
Riedel's  intention  at  first  to  cut  across  the  duct  completely 
and  to  implant  the  severed  end  in  the  duodenum,  but, 
abandoning  this  idea,  he  united  by  lateral  anastomosis 
the  dilated  duct  to  the  bowel.  The  patient  died  as  a 
result  of  the  leakage  of  infected  bile  into  the  general  peri- 
toneal cavity.  Kocher  in  1890  operated  upon  a  patient 
in  whose  common  duct  two  stones  w^ere  impacted.  The 
duct  behind  the  block  was  greatly  dilated  and  it  was  his 
intention  to  unite  the  duct  to  the  duodenum  lying  in  con- 
tact with  it,  and  sutures  were  introduced  for  the  purpose. 
The  obstruction  of  the  duct,  however,  was  relieved  by  the 
breaking  up  of  the  stones,  and  the  opening,  therefore, 
was  not  made.  Sprengel  in  1891  reported  the  first 
recovery  after  this  operation,  the  patient  being  a  woman 
upon  whom  he  had  previously  performed  cholecystec- 
tomy. During  the  first  operation  the  greatly  dilated 
duct  was  mistaken  for  the  duodenum,  and  a  calculus  felt 
therein  was  pushed  onwards. 

Several  operations  have  been  done  under  the  impression 
that  a  cholecystenterostomy  was  being  performed — the 
exact  conditions  only  being  made  clear  at  an  autopsy. 

The  anastomosis  has  been  effected  either  by  simple 
suture  or  by  the  aid  of  mechanical  appliances,  such  as 
Murphy's  button,  as  in  Czerny's  case,  or  Boari's  button. 


Choledocho-enter.ostomy  365 

The  method  of  lateral  approximation  has  been  always 
adopted. 

The  following  case  is  related  by  Swain  (Lancet,  vol. 
I,  1895,  p.  743): 

On  October  12,  1894,  I  was  asked  by  Dr.  Clay  to  see 
a  girl  aged  seventeen  years  who  had  been  brought  to  him 
for  the  first  time  on  the  preceding  day.  She  had  been 
ailing  more  or  less  for  two  years.  In  January,  1894,  she 
became  jaundiced,  and  a  swelling  formed  under  the  liver. 
She  had  been  treated  by  two  medical  men  with  mercury 
and  other  drugs;  but  in  spite  of  their  treatment  the 
jaundice  deepened  and  the  swelling  under  the  liver  in- 
creased in  size.  They  appear  then  to  have  told  the 
parents  that  nothing  more  could  be  done,  whereupon  Dr. 
Clay  was  consulted.  The  condition  of  the  patient  when 
I  saw  her  was  briefly  as  follows:  She  was  very  deeply 
jaundiced ;  the  urine  was  the  colour  of  porter.  The  stools 
were  white.  She  suffered  no  particular  pain,  had  not  been 
sick,  and  throughout  her  illness  neither  of  these  symp- 
toms had  been  present.  She  was  much  emaciated.  There 
was  a  large  abdominal  tumour  reaching  from  below  the 
liver  to  the  brim  of  the  pelvis  and  across  the  abdomen 
obliquely,  about  three  inches  to  the  left  of  the  umbilicus. 
The  whole  swelling  w^as  absolutely  dull  on  percussion,  and 
the  merest  tap  on  any  part  of  it  produced  a  thrill  of 
fluctuation.  Taking  the  sum  of  her  symptoms,  we  had 
little  doubt  that  it  was  distended  gall-bladder,  although 
the  possibility  of  a  hydatid  cyst  was  suggested.  I  as- 
pirated the  tumour  w4th  a  full-sized  aspirating  needle, 
and  we  immediately  perceived  the  characteristic  fluid 
of  distended  gall-bladder.  As  if  to  make  assurance 
doubly  sure,  towards  the  latter  end  of  the  aspiration  a 
gall-stone  struck  the  cannula  repeatedly,  and  the  click 
of  impact  was  heard  by  Dr.  Clay,  the  father,  and  myself. 


v) 


66  Operations  on   Common   Duct 


The  quantity  of  fluid  withdrawn  was  six  pints  and  one 
ounce.  No  evil  results  followed  the  aspiration,  and  I  did 
not  see  the  patient  again  until  October  17th,  when  I  found 
that  the  swelling  was  as  large  as  ever.  We  then  advised 
that  an  operation  should  be  performed,  and  for  this  pur- 
pose she  was  removed  to  the  private  home  for  patients, 
and  on  the  following  day  I  operated  on  her.  An  incision 
about  four  inches  long  was  made  a  little  to  the  outer  side 
of  the  right  linea  semilunaris.  The  integuments  were 
very  thinly  spread  over  the  tumour  and  the  peritoneum 
was  rapidly  reached  and  opened.  The  cyst,  being  ex- 
posed and  packed  well  round  with  small  sponges,  was 
tapped  with  an  aspirating  needle.  Fluid  of  the  same 
character  as  before  was  withdrawn,  but  to  the  amount  of 
seven  pints  and  twelve  ounces.  On  passing  the  hand  into 
the  abdominal  cavity  the  cyst  was  found  to  be  firmly 
adherent  to  the  intestine  in  all  directions,  the  transverse 
colon  being  spread  out  over  it.  A  small  opening  was 
now  made,  sufficiently  large  to  admit  the  forefinger.  The 
cyst  wall  was  very  thin,  but  tough.  Externally,  it 
was  of  a  dark  chocolate  colour;  the  cut  edge  was  rather 
white,  and  the  interior  bile  stained.  On  introducing  the 
forefinger  after  a  prolonged  search  no  gall-stone  could  be 
found,  although,  as  previously  stated,  the  presence  of  one 
could  not  be  doubted.  The  finger  passed  upwards  and 
inwards  towards  the  liver  into  a  passage  with  a  crescentic 
opening,  which  I  believed  to  be  common  bile-duct;  but 
a  probe  passed  down  far  beyond  the  finger  impinged  on  no 
stone.  Up  to  this  time  I  had  no  doubt  but  that  I  was 
dealing  with  a  huge,  dilated  gall-bladder;  but  my  as- 
tonishment may  be  appreciated  when  I  found,  in  the 
course  of  further  investigation  as  to  the  relations  of  the 
parts  outside  the  cyst,  the  gall-bladder  in  its  normal 
position,  somewhat  pale  in  colour,  undistended  by  bile, 
and  containing  no  gall-stones.  The  question  now  arose 
as  to  what  course  was  the  best  to  pursue.     To  remove 


Choledochectomy  2)^'] 

the  cyst  was  impossible.  To  stitch  it  to  the  parietes 
seemed  to  condemn  the  patient  to  a  perpetual  fistula, 
or,  at  any  rate,  to  very  prolonged  drainage.  I  decided, 
therefore,  to  accept  the  other  alternative  and  to  attach 
the  cyst  to  the  intestine.  Without  much  trouble  I 
succeeded  in  drawing  up  a  good  coil  of  jejunum  close 
to  the  duodenum.  My  great  difficulty  was  to  get  a 
good  surface  on  the  cyst.  In  order  to  do  this  I  had  to 
tear  through  the  two  layers  of  the  mesocolon,  and  even 
then  the  surface  obtained  was  limited.  The  cyst  was 
then  rapidly  attached  to  the  bowel  by  Murphy's  button 
in  the  manner  described  by  him.  The  small  original 
opening  made  to  explore  the  cyst  was  closed  with  Lem- 
bert's  sutures.  The  peritoneal  cavity,  which  had  been 
thoroughly  well  packed  with  sponges,  was  now  cleansed, 
and  the  pouch  to  the  outer  side  and  beneath  the  liver 
drained  with  a  Keith's  tube.  The  wound  was  closed 
with  silkworm-gut  sutures. 

A  case  is  recorded  by  Terrier,  in  which,  after  the  anasto- 
mosis of  a  dilated  duct  to  the  upper  part  of  the  duo- 
denum, the  bile  flowed  backwards  into  the  stomach  and 
was  vomited  in  large  quantities. 

A  case  of  choledocho-enterostomy  is  also  recorded  by 
Brenner  (Virch.  Archiv,  Nov.,  1899,  vol.  158,  part  2). 

The  operation  of  choledocho-duodenostomy  has  been 
already  described. 


CHOLEDOCHECTOMY. 

Removal  of  a  portion  of  the  common  duct  with  sub- 
sequent suture  was  performed  first  by  E.  Doyen.  The 
case  was  one  of  stone  impacted  in  the  upper  part  of  the 
common  duct ;  in  extracting  the  stone  the  duct  was  torn 


368 


Operations  on   Common   Duct 


through.  The  frayed  ends  were  trimmed  and  the  ends 
sutured  over  a  rubber  tube.  The  figures  explain  the 
various  steps  of  the  operation. 

Kehr  records  a  case  in  which  a  stricture  of  the  common 
duct  was  excised.  The  posterior  part  of  the  duct  alone 
was  united;  through  the  anterior  part  a  drainage-tube 
was  passed  upwards  to  the  hepatic  duct.     The  patient 


Fig.  71. — Doyen's  case  of  choledocliectomy:  a.  Shews  the  stone 
in  the  common  duct,  just  beyond  the  jtinction  of  the  hepatic  and 
cystic  ducts;  b.  shews  the  duct  ruptured  after  extraction  of  the  stone; 
c  and  d,  the  duct  sutured   after  removal  of  the  frayed  edges  seen  in  b. 


recovered,  though  the  hepatic  cells  were  so  damaged  that 
no  bile  flowed  through  the  tube  at  first ;  for  several  weeks 
a  very  small  quantity  only  was  passed.  The  fistula 
eventually  closed. 

\V.  J.  Mayo  (Med.  Record.  April  30,  1904)  records 
three  cases  in  which  portions  of  the  common  duct  were 
excised  for  malignant  disease.  In  the  first  the  gall- 
bladder, cvstic  duct,  and  one  inch  of   the  common  duct 


operations  Upon   Biliary  Fistulas  369 

were  excised.  The  ends  of  the  common  duct  were 
brought  together  in  three-fourths  of  their  circumference, 
the  remainder  being  left  open  for  drainage.  The  patient 
recovered.  In  the  second  case  the  proximal  end  of  the 
divided  duct  was  united  to  the  duodenum.  In  the  third 
case  a  malignant  tumour  of  the  common  duct  was  excised, 
with  end-to-end  suture.  This  patient  died  from  shock. 
Waring  and  Reynier  have  successfully  performed  the 
operation  of  excision  of  a  part  and  of  the  whole  of  the 
common  duct  in  dogs.  The  operation  deserves  to  be 
remembered,  as  in  certain  exceptional  instances  it  may  be 
necessary. 


OPERATIONS  UPON  BILIARY  FISTULA. 

External  Biliary  Fistula. — The  treatment  of  external 
biliary  fistulas  will  depend  entirely  upon  the  conditions 
which  produce  and  maintain  the  patency  of  the  external 
opening.  As  a  rule,  with  few  exceptions,  it  will  be  found 
that  the  passage  of  bile  through  an  external  fistula  is  due 
to  the  fact  that  this  is  the  direction  of  least  resistance. 
If  the  bile-ducts  are  clear  and  free  from  narrowing,  the 
bile  finds  its  easiest  course  along  them.  After  a  cholecys- 
totomy  it  is  sometimes,  as  in  cases  of  chronic  pancreati- 
tis, advisable  to  keep  the  opening  patent  for  several  weeks, 
and  to  accomplish  this  is  not  seldom  a  matter  of  the  great- 
est difficulty.  If,  therefore,  the  bile-passages  are  free,  an 
external  biliary  fistula  will  close  spontaneously. 

One  form  of  external  biliary  fistula  mentioned  by 
both  Riedel  and  Langenbuch  is  that  in  which  a  greatly 
dilated  gall-bladder  has  been  drained  after  cholecys- 
24 


370  Operations  on   Common   Duct 

totomy.  The  dragging  of  the  gall-bladder  fixed  in  the 
abdominal  wound  produces  a  kink  in  the  common  duct, 
and  the  passage  of  bile  to  the  intestine  is  therefore  pre- 
vented. In  such  circumstances  the  gall-bladder  may, 
as  Riedel  advises,  be  freed  and  the  opening  into  its  fundus 
sutured.  A  better  plan  would  be  to  remove  the  gall- 
bladder entirely. 

If  the  fistula  persist  after  the  operation  of  cholecys- 
totomy,  it  probably  indicates  that  a  stone  is  wedged 
in  the  common  duct.  In  this  and  in  all  cases  it  is  ad- 
visable to  make  a  bacteriological  examination  of  the  bile, 
and  to  delay  any  operative  intervention  until  the  fluid 
discharged  is  almost  sterile. 

The  treatment,  therefore,  of  an  external  biliary  fistula 
necessitates  at  the  first  a  very  thorough  examination  of 
all  the  bile  tract  and  the  discovery  of  the  condition  which 
is  responsible  for  the  prevention  of  the  normal  flow  of  the 
bile  into  the  intestine.  If  a  stone  be  found  in  the  common 
duct,  it  will  be  removed ;  if  there  be  a  stricture  of  the  duct, 
it  also  may  be  removed  or  cholecystenterostomy  may  be 
performed.  If  there  be  a  growth  or  an  inflammatory 
tumour  causing  obstruction  of  the  duct  by  pressure  from 
without,  or  by  blockage  from  within,  the  fistula  may  be 
left  as  a  permanent  drain,  or  a  cholecystenterostomy  may 
be  performed.  If,  after  the  removal  of  a  stone  in  the 
duct,  it  is  quite  certain  that  the  duct  is  clear,  the  gall- 
bladder may  be  removed.  Kleiber,  in  1892  (Dissert., 
Greifswald),  has  collected  the  records  of  thirty  cases  of 
fistula  in  which  cholecystectomy  was  performed. 

Internal  Biliary  Fistula. — -The  discovery  of  a  fistula 
between  the  bile  passages  and  the  intestine  will  generally 


Internal   Biliary  Fistula  371 

be  made  only  during  the  course  of  an  operation.  If  the 
fistula  connect  the  gall-bladder  or  the  cystic  duct,  on  the 
one  hand,  with  the  stomach,  duodenum  or  colon,  on  the 
other,  the  two  united  viscera  must  be  separated  with  the 
utmost  gentleness.  The  opening  into  the  intestine  is 
then  closed  by  suture,  and  the  gall-bladder  is,  by  prefer- 
ence, removed,  or  a  drain  is  introduced  through  the  open- 
ing. It  is  of  the  highest  importance  in  all  such  cases  to 
make  sure  that  the  passage  is  clear  for  the  bile.  If  there 
is  a  block  in  the  common  duct,  it  must  be  removed.  As 
a  rule,  a  stone  will  be  found  in  the  cystic  duct,  in  the 
common  duct  near  the  cystic  duct,  or  in  the  common 
duct  low  down.  If  choledochotomy  is  performed,  it  is 
wiser  to  afford  through  the  incision  a  direct  drainage  for 
some  days. 

Cases  of  fistula  between  the  bile  passages  and  the  uri- 
nary tract  or  the  lungs  may  also  be  dealt  with  success- 
fully by  operation,  the  stones  which  are  blocking  the 
hepatic  or  common  duct  being  removed  and  free  drainage 
established.  Instances  are  recorded  in  the  chapter 
dealing  with  biliary  fistulae. 


NDEX. 


Abdomen,  skin  of,  preparation  of, 

for  operation,  286 
Abdominal  distension  in  perfora- 
tion of  gall-bladder,  232 
wound,  closing  of,  306,  307 
Abscess,  biliary,   87 

from  stone  in  hepatic  duct, 

176 
of  liver,  89 
subphrenic,    from   occlusion   of 

common  duct,    196 
with  chronic  perforation  of  gall- 
bladder, 249 
Adhesions,  stripping  of,  304 
Adipose  gall-bladder,  67 
Age,  gall-stones  and,  51 
Albumin    in    tirine    in    gall-stone 

disease,   144 
Alimentary  canal,  preparation  of, 

for  operation,  285 
Amorphous  gall-stones,   32 
Ampulla  of  Vater,  22,  26 

stones  in,  operation  for,  345 
Anastomosis    of    common     duct, 

355 
Anatomy  of  bile-ducts,  17 

of  gall-bladder,  17 
Appendicitis,    acute   cholecystitis 
and,  163 

gall-stones  and,  49 
Assistants,     preparation     of,     for 

operating,   277 
Atrophy     of     gall-bladder     wall, 
from  gall-stones,   78 

of  liver  from  gall-stone  disease. 


Bacillus  coli  in  acute  cholecj^sti- 
tis,    163 
in  biliary  abscess,  87 
in  gall-stones,  36,  146 
of  Eberth  in  acute  cholecystitis, 

163 
typhosus,  gall-stones  from,  36, 

39 
in  bile,  38,  39 
in  biliary  abscess,  87 
Bacteria  causing  gall-stones,  43 
entrance  of,  into  bile  passages, 

47 
into  gall-bladder,  47 
through  common  duct,  47 
through  portal  circ-alation,  47 
gall-stones  from,  36 
in  bile,  37 

in  biliary  abscess,  87 
in  gall-stones,  146 
Bevan's  incision,  301,  302 
Bichloride  of  mercury,  gall-stones 

from ,    3  6 
Bile   and   urinary   tracts,    tistuke 
between,    217 
bacillus  typhosus  in,  36,  39 
bacteria  in,   36 

passages   and   female    genitals, 
fistulae  between,  218 
and  pleura,  fistulas  between, 

220 
and   thoracic    organ,    fistulas 

between ,   220 
casts  of,  as  gall-stones,  32 
entrance  of  bacteria  into,  47 
retention  of,  gall-stones  and,  43 


373 


174 


Index 


Bile,  secretion-pressure  of,  80 
stasis  of,  gall-stones  and,  43,  50 
sterility  of,   37 
Bile-ducts,  anatomy  of,  17 
cancer  of,  100 
carcinoma  of,  100 
common,  21.     See  also  Coiiuiion 

duct. 
cystic,  20,  21.     See  also  Cystic 

duct. 
hepatic,   21.      See  also  Hepatic 

duct. 
operations  on,  293 

anti-operative        treatment, 

307 
Bevan's  incision  for,  301,  302 
closing  wound,  306,  307 
Courvoisier's  incision  for,  302 
general  observations,  299 
history,   293 
incisions  for,  300 
Kehr's  incision  for,  302 
Kocher's    incision    for,    301, 

302 
Mayo     Robson     incision  for, 

300,   301 
position  of  patient,  299 
sand-bag  in,  299 
swabs  in,  303 
technique,   299 
walls  of,  structure,  30 
Biliary  abscess,  87 

from  stone  in  hepatic   duct, 

176 
of  liver,  89 
fistulas,   204 
external,   205 

operations  for,  369 
internal,   206 

operation  for,  370 
operation  upon,  369 
treatment,  321 
infection  in  typhoid  fever,  39 
Bilirubin  gall-stones,  mixed,  32 
Bilirubin-calcium     gall-stones, 
pure,  32 


Bilirubin-calcium,  origin,   35 
Blood-serum    test    for    jaundice, 
125 


Calcification      of     gall-bladder 
from  gall-stone  disease,  74 
from   stones   in   cystic   duct, 
169 
Calcitun-bilirubin     gall-stones, 
pure,   32 
origin  of,  35 
Canal  of  Wirsung,  22 
Cancer.      See  Carcinoma. 
Carbolic  acid,  gall-stones  from,  36 
Carcinoma  from  gall-stones,  99 
jaundice  in,  127 
of  bile-ducts,  100 
of  gall-bladder  after  cholecys- 
totomy,   102,   325 
gall-stones  and,  324 
Casts    of   bile   passages     as    gall- 
stones,  32 
Catarrh,  lithogenovis,  36 
Catgut,  sterilization  of,  280 
Celluloid  thread,   Pagenstecher's, 

for  ligatures,   281 
Chalk  gall-stones,  32 
Cholangitis,     membranous,    from 
gall-stone  disease,  89 
suppurative,  extension  of,  88 
from  gall-stone  disease,  86 
from  typhoid,  87 
pneumococcus  in,  87 
with  occlusion  of  cominon  duct, 
195, 196 
Cholecystectomy,   317,   322 
advantages  of,  327 
digestion   and,   326 
disadvantage  of,  328 
drainage  in,  324,  328,  332 
for  perforation  of  gall-bladder, 

indications  for,  319,  322 

kimbar,   334 

risk  involved,  327 


Index 


375 


Cholecystectomy,  technique,  330 
Cholecystendesis,   312 
Cholecystenterostomy,  355 
Cholecyst gastrostomy,  357 
Cholecystitis,  acute,  appendicitis 
and,   163 
bacillus  coli  in,  163 
Eberth's  bacillus  in,  163 
from   stones   in   cystic   duct, 
161 
in  gall-bladder,  147 
gall-bladder  in,  148 
pneumococcus  in,  163 
staphylococcus  in,  163 
streptococcus  pyogenes  albus 
in,   163 
aureus  in,  163 
chronic,   from  stones  in  cystic 
duct,   164 
in  gall-bladder,  148,  149 
from  gall-stone  disease,  57 

oedema  with,  64 
membranous,    from    gall-stone 

disease,   89 
phlegmonous,    from    stones    in 
cystic  duct,   165 
symptoms,   168 
with  perforation  of  gall-blad- 
der,  248 
Cholecystotomy,  309 

carcinoma  after,  102,  325 
closing  wound,  316 
drainage  after,  314,  315 
end-results,  311 
fixing  gall-bladder  after,  316 
ideal,  312 

indications  for,  309,  319 
lumbar,  334 
on  left  side,  334 
technique,   311 
Choledochectomy,  367 
Choledocho-duodenal  fistulae  from 

gall-stone  disease,  215 
Choledocho-duodenostomy,  349 
Choledocho-enterostomy,  364 
Choledochostomy,  358 


Choledochotomy,   339 

for  stone  in  common  duct,  198- 

201 
lumbar,   354 
retrodtiodenal,  344 
supraduodenal,   339 

closing  wounds  after,  343 
digital  exploration  in,  341 
drainage  in,  342 
position  of  patient,  340 
transduodenal,  345 
Cholelithiasis.        See       Gall-stone 

disease. 
Cholelithotrity,  317,  318 
Cholesterin      gall-stones,      lamin- 
ated,  31 
pure,   31 
origin  of,  35 
Cigarette  drain,  283 
Colic  in  gall-stone  disease,   117 

cause  of,   122 
Comtnon  dtict,  21 
access  to,  28 
anastomosis  of,  355 
and    duodenum,    fistula    be- 
tween, 84 
changes  in,  from  gall-stones, 

79 

diameter  of,   28 

dilatation  of,  79 

distension   of,   80 

diverticula  of,  77 

entrance  of  bacteria  l)y,  47 

fistulas  into,  225 

inflammation  of,  pericholan- 
gitis from,  86 

impermeable  obstruction  of, 
operations  for,   354 

interstitial  portion,  26 

irremovable    obstruction    of, 
operations  for,  354 

occlusion  of,  cholangitis  with, 
195,   196 
cholecystenterostomy    for, 

355 
choledochectomy    for,    367 


I 


376 


Index 


Common  duct,  occlusion  of,    cho- 
Icdocho  -  duodcnostomy 
for,  349 
choledocho   -   enterostomy 

for,  364 
choledochostomy   for,    358 
choledochotomy  for,    198- 
201,    339-         See       also 
Choledochotomy. 
cholelithotrity  for,  318 
complete,   184 
differential   diagnosis,    201 
difficulties     of     diagnosis, 

352 
duodeno  -  choledochotomy 

for,   197.  345 
impermeable,       operations 

for,  354 
jaundice  in,  202 
loss  of  weight  from,  192 
operations  for,  339 
pancreatitis  and,  differen- 
tiation,  202 
pancreatitis  from,  197 
partial,   185 

cause  of  attacks,  195 
chronic ,    191 
jaundice  in,  189 
steeple    chart    in,      133, 

190 
symptoms,  18S 
temperature  in,  190 
subphrenic    abscess    from, 

196 
symptoms,   184 
pancreatic  portion,  23 
perforation  of  stone  into  por- 
tal vein  from,  223 
relations  of,  22 
retroduodenal  ]jortion,  23 
stenosis  of,  93 
stones  in.      See  Conuiuni  duct. 

occlu.'iion  of. 
stricture  of,  93 
supraduodenal  portion,  22 
transduodenal  portion,  26 


C(jnnnon      duct,       wide-mouthed 

o])ening  of,  84 
Constipation  in  gall-stone  disease , 

143 
Corset  liver,  gall-stones  and,  50 
Courvoisier's  incision,  302 

law,   130 
Cystic  arter\",  20 
duct,  20,  21 
access  to,  28 
blocking  of,  84 
stones  in,  acute  cholecystitis 
from ,    161 
calcification  of  gall-bladder 

from,   169 
cholecystectomy  for,  317 
cholelithotrity     for,      317, 

318 
chronic  cholecystitis  from, 

164 
cysticotomy  for,   317,   318 
dilatation    of    gall-bladder 

from,   152 
empyema  from,   156 
hydrops  from,  154 
jaundice  from,  159 
operations  for,  317 
peritonitis  from,   165 
phlegmonotis   cholecystitis 

from ,    165 
pressure  effects  of,  169 
rupture      of      gall-bladder 

from ,   158 
sclerosis     of     gall-bladder 

from,    169 
symptoms,    151 
ulceration  of  stones  through, 
229 
Cysticotomy,  317,  318 
Cysto-colic     fistula;      from      .gall- 
stone disease,  212,  216 
Cysto-duodenal  fistula  from  gall- 
stone disease,  207,  212 

Diagnosis   of   gall-stone   disease, 
differential,   138 


Index 


111 


Diagnosis   of  gall-stones   in   com- 
mon duct,  differential,   201 

Diet  after  operation,  290 

Digestion,   cholecystectomy   and, 
326 

Dilatation    of    gall-bladder    from 
stones  in  cystic  duct,  152 

Diverticula   from    gall-stone    dis- 
ease,  75 
of  common  duct,  77 

Diverticulum  of  Vater,  22,  26 
stones  in,  76 

Drainage   after  cholecystectomy, 

324 

after  cholecystotomy,  314,  315 

in  cholecystectomy,  328,  332 

in  choledochotomy,   supraduo- 
denal,  342 

in    operations    for    gall-stones, 
328 

material,  282 

cigarette  drain  as,  283 
split  rubber  tube  as,  283 
Duct,    common,     21.       See    also 
Common  duct. 

cystic,  20,  21.     See  also  Cystic 
duct. 

hepatic,   21.      See  also  Hepatic 
duct. 

stricture  of,  from  gall-stone  dis- 
ease, 93 
Duodeno-choledochotomy,   345 

for    stone     in     common     duct, 
197 
Duodenum    and    common    duct, 
fistula  between,  4S4 
stone  in,  256 
ulceration  into,  85 


Eberth's  bacillus  in  acute  chole- 
cystitis,   163 

Elliott's  position  for  operation, 
299 

Empyema,  enlargement  of  gall- 
bladder in,    72 


Empyema  from  stones  in   cystic 
duct,  156 
in  gall-stone  disease,  68 
of  gall-bladder,  68 


Female  genitals  and  bile  passages, 

fistulse  between  ,218 
Fever  in  gall-stone  disease,   132, 
142 
in  partial  occlusion  of  common 
duct,    189,    190 
Fistulas    between     stomach     and 
gall-bladder,  208,  212 
between     bile     passages      and 
female  genitals,  218 
and  pleura,  220 
and  thoracic  organs,  220 
and  virinary  tract,  217 
between  common  duct  and  por- 
tal vein,  223 
biliary,  204 
external,   205 
internal,   206 
operations,  upon,  369 
treatment ,   321 
choledocho-duodenal,   215 
cysto-colic,  212,  216 
cysto-duodenal,  207,  212 
intestinal       obstruction       and, 

2  16 
into  common  duct,  225 
into  hepatic  duct,  225 
into  uterus,  219 
Floating   lobe    in    gall-stone    dis- 
ease,   108 
Foecal     vomiting      in      intestinal 
obstruction     from     gall-stones, 

259 
FoL'tus,  gall-stones  in,  46 
Foramen  of  Winslow,  23 
Forceps,  gall-stone,  303 
Foreign  bodies,  gall-stones  from, 

44 
Frrenum  caruncul;e,  22 


178 


Index 


Gall-bladder,  adipose,  67 
anatomy  of,  17 
and  stomach,   fistula  between, 

208,   212 
atrophy  of  wall  of,  from  gall- 
stones,  78 
calcification  of,  from  gall-stone 
disease,   74 

from   stones   in   cystic    duct, 
169 
carcinoma  of,  after  cholecystot- 
omy,  102,  325 

from  gall-stones,  99 

gall-stones  and,  324 
contracted,    gall-stone    disease 

and,    128 
dilatation    of,    from    stones    in 

cystic  duct,  152 
dilated,   70 

distension  of,  jaundice  and,  127 
diverticula  of,   from  gall-stone 

disease,    75 
empyema  of,  68 

from   stones   in   cystic   duct, 
156 
enlargements  of,  70 

in  empyema,  72 
entrance  of  bacteria  into,  47 
fixing,     after    cholecystotomy, 

316 
freeing  of,  from  adhesions,  304 
gangrene  of,  167 
hemorrhage  from,  94 
hour-glass,  65 
hydrops     of,     from     stones     in 

cystic  duct,   154 
hypersensitiveness   of,   in   gall- 
stone disease,  112, 116, 150 
hypertrophy     of     muscles     of, 

from  gall-stones,  57 
in  acute  cholecystitis,  14S 
inflammatory  changes  in,  57 
multilocular  appearance  of,  66 
operations  on,  293 

anti-operative  treatment,  307 

Bevan's  incision,  301,  302 


Gall-bladder,   operations  on,  clos- 
ing wound,  306,  307 

Courvoisier's  incision,  302 

general  observations,  299 

history,   293 

incisions  for,  300 

Kehr's  incision,  302 

Kocher's  incision,  301,  302 

Mayo    Robson    incision    for, 
300,   301 

position  of  patient,  299 

sand-bag  in,  299 

swabs  in,  303 

technique,   299 
ossification  of,  from  gall-stones, 

74 
papillomata  from,  99 
passage  of  stone  from,  to  duo- 
denum, symptoms,  140 
perforation  of,  165,  167,  226 

abdominal  distension  in,  232 

acute,  230 

cholecystectomy  for,  233 

chronic,  with  abscess,  249 

diagnosis,  231 

from   stones   in   cystic   duct, 

158 
into  peritoneal  cavit)',  230 
operation  for,  232 
pain  in,  231 
peritonitis  from,  230 
phlegmonous        cholecystitis 

with,   248 
through  neck,  229 
treatment ,   232 
rupture  of,  165,  167,  226.     See 
also  Gall-bladder,  perforation 

of. 
sclerosis     of,     from    stones     in 

cystic  duct,   169 
secondary,  76,  227 
size  of,  in  hydrops,  70 
sloughing  of,  165 
stones    in,    acute    cholecystitis 
from,   147 

cholecystotomy  for,  309 


Index 


379 


Gall-bladder,   stones    in,  chronic 
cholecystitis  from,  148,  149 
death  from  pressure  of,  150 
ordinary,   31 
symptoms  from,  145 
tenderness  of,  in  gall-stone  dis- 
ease, III,  112,  116,  150 
tumour    of,    in    gall-stone    dis- 
ease, 134 
inflation  of  stomach  in  diag- 
nosis,  136 
ulceration  of,  67,  229 
walls  of,  structure,  30 

thickness     of,    in     gall-stone 
disease,  64 
Gall-stone    disease,    acute    chole- 
cystitis     in ,      from 
stones      in      cystic 
duct,    161 
in  gall-bladder,  147 
albumin  in  urine  in,  144 
arrestment  of  stones,  symp- 
toms from,  145 
atrophy  of  gall-bladder  wall 
from,  78 
of  liver  from,  107 
biliary  abscess  in,  from  stone 
in  hepatic  duct,  176 
fistulas  in,  treatment,   321 
calcification    of    gall-bladder 
in,  74 
from    stones    in    cystic 
duct,   169 
cancer  from,  99 

of  ducts  from,  100 
carcinoma  from,  99 

of  gall-bladder  and,  324 
changes  in  common  duct  in, 

79 

cholangitis  from,  membran- 
ous, 89 

cholecystectomy  for,  317, 
322.  See  also  Cholecystec- 
tomy. 

cholecystenterostomy  for, 
355 


Gall-stone    disease,    cholecystitis 
from,  57 

membranous,  89 

oedema  with,  64 
cholecystotomy      for,      309. 

See  also  Cholecystotomy. 
choledochectomy  for,  367 
choledocho  -  duodenostomy 

for,  349 
choledocho-enterostomy   for, 

364 
choledochostomy  for,  358 
choledochotomy      for,      339. 

See  also  Choledochotomy. 
cholelithotrity  for,  317,  318 
chronic  cholecystitis  in,  from 
stones      in      cystic 
duct,   164 
in    gall-bladder,     148, 
149 
colic  in,  117 

cause  of,  122 
consequences  of,  204 
constipation  in,   143 
contracted  gall-bladder  and, 

128 
cysticotomy  for,  317,  318 
diagnosis,  differential,  138 
dilatation  of  gall-bladder  in, 
from  stone  in  cystic  duct, 
152 
diverticula  from,  75 
duodeno    -     choledochotomy 

for,  345 
empyema  in,  68 

from  stones  in  cystic  duct, 
156 
enlargement  of  liver  in,  137 
fistulas    from,    between    bile 
passages  and  female 
genitals,   218 
and  pleura,  220 
and  thoracic  organ  ,220 
and  urinary  tract  ,217 
between  common  dvict  and 
portal  vein,  223 


;8o 


Index 


Gall-stone   disease,   fistulas  from, 
between      stomach     and 
gall-bladder,  208,  212 
biliary,      204.        See     also 

Biliary  fistiilcc. 
choledocho-duodenal,  215 
cysto-colic ,  212.  216 
cysto-duodenal,  207,  212 
into  common  duct,  225 
into  hepatic  duct,  225 
into  uterus,  219 
fever  in,  132.  142 
floating  lobe  in,  108 
frequency  of,   109 
haemorrhage  in,   94 
hepatic  abscesses  from,  89 
hepaticolithotripsy  for,  338 
hepaticostomy  for,  337 
hepaticotomy  for,  178,  335 
hydrops  in,  68 

from  stones  in  cystic  duct, 

154 
hypersensitiveness     of     gall- 
bladder in,    III,  112,    116, 

150 
hypertrophy    of    muscles    of 

gall-bladder  from,  57 
intestinal  obstruction  in ,  216, 

252.      See     also    Intestinal 

obstruction  from  gall-stones. 
irregular.  140 
jaundice  in,   125,   143.        See 

also  Jaundice  in  gall-stone 

disease. 
linguiform    process    of    liver 

in,    108 
liver  changes  in,  106 
malignant  disease  from,  98 
nausea  in,   123 
operations  for,  293 

after-treatment,  290 

catgvit  for,  280 

celluloid    thread    for   liga- 
tures, 281 

diet  after,  290 

drainage  in,  328 


Gall-stone  disease,  operations  for. 
drainage  in,  material  for, 
282 
garments  for  patient,  2 89 

for  surgeon,  270 
gloves  for,  275 
Pagenstecher's        celluloid 
thread  for  ligatures,  281 
preparations  for,  270 
of  assistants,  277 
of  hands,  273 
of  nurses,  272,  277 
of  patients,  284 
of  surgeon,  270 
room  for,  289 
rubber  dam  in,  288 
suture  material  for,  280 
swabs  for,  278 
ossification     of     gall-bladder 

from,   74 
pain  in,  1 1 1,  141 
local.  III 
referred,   115 

stomach  diseases  and,  114 
pancreatitis   in,    197 
papillomata  from,  99 
patholog\'  of,  57 
perforation  of  gall-bladder  in, 
165,     167,    226.      See    also 
Gall-bladder,  perforation  of. 
pericholecystitis  in,  72 
phlegmonous  cholecvstitis  in. 

165 
symptoms,  168 
pressure  eff^ects  of  stones  in 
cystic  duct,   169 
symptoms,  112,  150 
pulse  in,  143 
recognition,    109 
regular,  140 
Riedel's  lobe  and,  107 
rigors  in,  132,  142 
rupture  of  gall-bladder  in ,  1 6  5 , 
167,  226.      See  also  Gall- 
bladder, perforation  of. 
of  hepatic  duct  in,  181 


Index 


l8i 


Gall-stone  disease,  sclerosis  of  gall- 
bladder in,  from  stones  in 
cystic  duct,  169 
signs  of,  109 
sloughing  of  gall-bladder  in , 

165 
steeple  temperature  chart  in, 

133.  190 
stenosis     of     common     dnct 

from,  93 
stones  in  common  duct.     See 
Common    duct,    occlusion 
of. 
in  cystic  dvict,  symptoms, 

151 
in  gall-bladder,  syinptoms, 

145 
in     hepatic     duct,     s>'mp- 
toms,   174 
stricture    of     common    duct 

froin,  93 
subphrenic  abscess  in,  196 
suppurative  cholangitis  from, 

86 
symptoms,  109 

of  arrestment  of  stone,  145 
of  passage   of   stone   from 
bladder    to     duodenum, 
141 
of  stones  in  common  bile- 
duct,  184 
in  cystic  duct,  151 
in  gall-bladder,  145 
in  hepatic  duct,  174 
pressure,  112,  150 
special,   140 
temperature  in,   132 
tenderness  of  gall-bladder  in, 

III,  112,  116,  150 
tetany  in,  142 
thickness  of  gall-bladder  wall 

in,  64 
tvmiours  in,   134 

inflation     of     stomach     in 
diagnosis,  136 
typhoid  fever  and,  88 


Gall-stone    disease,    volvulus    in, 

255 

vomiting  in,  123,  142 
forceps,  303 
scoop,  303 
Gall-stones,  age  and,  51 
amorphous,   32 
appendicitis  and,  49 
bacillus  coli  in,  146 
bacteria  causing,  43 
bacteria  in,   146 
bilirubin,  mixed,  32 
bilirubin-calcium ,  origin,  35 

pure,  32 
calcium-bilirubin ,  origin,  35 

pure,  32 
chalk,  32 
cholesterin,  laminated,  31 

origin,  35 

pure,  31 
concretions  arovmd  foreign  bod- 
ies as,  32 
constitutional  conditions  and.  50 
corset  liver  and,  50 
experimental  formation,  41 
formation  of,  35 

experimental,  41 

time  needed,  46 
frequency,  109 
from  bacillus  coli,  36 

typhosus,  36,  39 
from  bacteria,  36 
from  bichloride  of  mercury,  36 
from  carbolic  acid,  36 
from  foreign  bodies,  44 
from  mercury  bichloride,  36 
from  metabolic  alterations,  51 
from  ricin,  36 
from  staphylococcus  pyogenes, 

36 
from  typhoid  bacillus,  36,  39 
gall-bladder,  ordinary 
impaction  of,  in  duodenum,  256 
in  common  bile-duct,  184.      See 

also Commonduct,  occlusion  of. 
in  cystic  duct,  operations  for,  3 1  7 


;82 


Index 


Gall-stones  in  cystic  duct,  symp- 
toms, 151 
in  diverticula,  76 
in  foetus,  46 
in  hepatic  duct,  174 
in  infancy,  53 
in  omental  adhesions,  227 
in  portal  vein,  174 
intestinal      obstruction      from, 
252.      See  also  Intestinal  ob- 
struciion  from  gall-stones. 
intramucous,  59 
intra-uterine,  formation,  55 
number  of,  32 

pressure  of,  death  from,   150 
rarer  forms,  32 
recognition  of,  109 
retention  of  bile  and,  43 
sex  and,  51 
size  of,  34 

increase  in,  49 
staphylococcus  pyogenes  albus 
in,  146 
aureus  in,  146 
stasis  of  bile  and,  43,  50 
ulceration  of,  into  portal  vein, 
230 
through  cystic  duct,  229 
through  neck  of  gall-bladder, 
229 
varieties  of,  31 
volvulus  from,  255 
vomiting  of,  210 
Gangrene  of  gall-bladder,  167 
Garments  for  patient,  289 

for  surgeon,  270 
Gastric    disturbances    in     partial 
occlusion      of    common      duct, 
192 
Genitals,   female,    and    bile    pas- 
sages, fistulje  between,  218 
Gloves  for  operation,  275 
sterilization  of,  275 

H.^MORRHAGE  from  gall-stones,  94 
jaundice  and,  94 


Hamel's  serum  test  for  jaundice, 

125 
Hands,  sterilization  of,  273 
Heister's  valves,  20 
Hepatic   abscess   from   gall-stone 
disease,   88 
duct,  21 

access  to,  28 

fistulae  into,  225 

rupture  of,  from  stones,  181 

stones  in,   174 

biliary  abscess  from,  176 
hepaticolithotripsy  for,  338 
hepaticostomy  for,  337 
hepaticotomy  for,  178,  335 
operations  for,  335 
Hepaticolithotripsy,  338 
Hepaticostomy,  337 
subhepatic,  337 
transhepatic,  337 
Hepaticotomy,  178,  335 
Hour-glass  gall-bladder,  65 
Hydrops    froin    stones    in    cystic 
duct,  154 
in  gall-stone  disease,  68 
Hypersensitiveness    of    gall-blad- 
der in   gall-stone   disease,   iii, 
112, 116, 150 
Hypertrophy  of  muscles  of  gall- 
bladder from  gall-stones,  57 

Icterus.      See  Jaundice. 
Ideal  cholecystotomy,  312 
Ileo-ca:cal    valve,    gall-stone    ob- 
struction and,  257 
Incisions  for  gall-bladder  opera- 
tions, 300 
Incisura  vesicalis,  17 
Infancy,  gall-stones  in,  53 
Instruments  for  operation,  steri- 
lization of,  280 
Intestinal  obstruction  from  gall- 
stones, 216,  252 
age  and,  252 
channel  of  stone,  252 
faecal  vomiting  in,  259 


Index 


Intestinal  obstruction  from  gall- 
stones, frequency  of,  252 
ileo-cJEcal  valve  and,  257 
medical  treatment,  266 
operation  for,  267 
prognosis,  264 
site  of  lodgment,  254 
spontaneous  recovery,  264 
stone  in  duodenum,  256 
symptoms,  257 
treatment,  266 
vomiting  in,   258 

Intramucous  gall-stones,  5g 

Intra-uterine   formation   of   gall- 
stones, 55 

Irregtilar  cholelithiasis,   140 


Jaundice,   blood-serum  test   for, 

125 
from    stones     in     cvstic 


159 
eall-bladder 


duct, 
and, 


distension 
127 
haemorrhage  and,  94 
in  carcinoma,  127 
in  gall-stone  disease,  125,  143 
causes,  126 
character,  126 
detection,  125 
frequency,  125 
seruin  test  for,  125 
in  malignant  disease,  127 
in  occlusion  of  common  duct, 
202 
of  cystic  duct,  159 
in  partial  occlusion  of  common 
duct,  189 


Kehr's  incision,  302 

Kidneys,  examination  of,   before 

operation,  288 
Kocher's  incision,  301,  302 

operation  for  stones  in  common 
duct.  340 


Ligatures,  sterilization  of,  280 
Linguiform  lobe  of  Riedel,  107 
Lithogenous  catarrh,  36 
Liver,  atrophy  of,  from  gall-stone 
disease,  107 
changes    in    gall-stone    disease, 

106 
enlargement    of,    in    gall-stone 

disease,  137 
freeing     of,      from     adhesions, 

304 
in  chronic  occlusion  of  coinmon 

duct,  191 
linguiform  process   of,   in   gall- 
stone disease,   108 
rotation      of,      through      Mayo 
Robson  incision,  305 
Local  pain  in  gall-stone   disease, 

III 
Lumbar  cholecystectomy,  334 
cholecystotomy,  334 
choledochotomy,  354 
Lyinphatic    glands    around    bile 
tract,  30 


Mayo  Robson  incision,  300,  301 
rotation  of  liver  through, 

305 

Mercury  bichloride,  gall-stones 
from,  36 

Metabolic  alterations,  gall-stones 
and,  51 

Mikulicz's  method  of  anasto- 
mosis of  common  duct,  358 

Mouth  of  patient,  preparation  of, 
for  operation,  285 

Moynihan's  sterilization  of  cat- 
gut, 2S1 


Nausea  in  gall-stone  disease,  123 
New-born,  gall-stones  in,  53 
Number  of  gall-stones,  32 
Nurses,  preparation  of,  for  opera- 
tion, 272,  277 


i84 


Index 


Oddi's  sphincter,  28 

(Edema  in  cholecystitis  from  gall- 
stones, 64 

Omental  adhesions,  gall-stones  in, 
227 

Operations  for  gall-stone  disease. 
See  (jaU-sto)ic  disease,  opera- 
tions for. 

Ossification  of  gall-bladder  from 
gall-stone  disease,   74 


Pagenstecher's  celluloid  thi-ead 

for  ligatures,  281 
Pain   in    gall-stone    disease,    in, 
141 
local,  III 
referred,   115 
in  partial  occlusion  of  common 

duct,   1 89 
in   perforation   of   gall-bladder, 

231 
Pancreatitis  from  stones  in  com- 
mon duct,   197 
occlusion  of  common  duct  and, 
differentiation,  202 
Papilla  major  of  Santorini,  22 
Papillomata  of  gall-bladder,  99 
Pathology'  of  gall-stone  disease,  57 
Patient,  anti-operative  treatment 

of,  307 
garments  for,  289 
position  of,  for  operation,  299 
in     choledochotomy,     supra- 
duodenal, 340 
preparation    of,    for   ojseration, 
2  84 
Perforation   of  gall-bladder,    165, 
167,  226.      See    also    Uall-blad- 
der,  perjoraUon  of. 
Pericholangitis     from     inflamma- 
tion of  common  duct,  86 
Pericholecystitis  in  gall-stone  dis- 
ease, 72 
Peritoneal  cavity,  perforation  of 
gall-bladder  into,  230 


Peritonitis    from    jjcrforation    of 
gall-bladder,  230 
from     stones     in    cystic     duct, 

165 
Pleura  and  bile  passages,  fistuUe 

between,  220 
Plica  longitudinalis,  22 
Pneumococcus  in  acute  cholecys- 
titis, 163 
Portal    circulation,     entrance    of 
bacteria  through,  47 
vein  and  common  duct,  fistul;e 
between,  223 
gall-stones  in,   174 
perforation     of     stone     into, 
from    coinmon    duct,    223, 
230 
Position  of  patient  for  operation, 

299 
Pressure  effects  of  stone  in  cystic 
duct,  169 
signs  of  gall-stone  disease,  iii. 
112,1 16,  150 
Pulse  in  gall-stone  disease,  143 
Pin-gatives  before  operation,  285 


Referred  pain  in  gall-stone  dis- 
ease ,115 
Regular  cholelithiasis,  140 
Ricin,  gall-stones  from,  36 
Riedel's    lobe,  gall-stone    disease 

and,   107 
Rigors  in  gall-stone  disease,  132. 

142 
Room  for  operation,  289 
Rubber  dam,  288 

gloves  for  operation,  275 

sterilization  of,  275 
tube,  split,  for  drainage,  283 
Rupture  of  gall-bladder,  165,  167, 
226.     See    also    Gall-bladder, 
perforation  of. 
of     hepatic     duct     from     gall- 
stones,   181 


Index 


385 


Sand-bag    in    operation    on    bile 

passages,  299 
Santorini's  papilla  major,  22 
Sclerosis     of     gall-bladder     from 

stones  in  cystic  duct,  169 
Scoops,  gall-stone,  303 
Secondary  gall-bladders,   76,   227 
Sex,  gall-stones  and,  51 
Signs  of  gall-stone  disease,  109 
Size  of  gall-stones,  34 
Skin  of  abdomen,  preparation  of, 

for  operation,  286 
Sloughing  of  gall-bladder,  165 
Sphincter  of  Oddi,  28 
Split   rubber  tube   for   drainage, 

283 
Staphylococcus  in  acute  cholecys- 
titis,  163 
pyogenes  albus  in  biliary  ab- 
cess,  87 
in  gall-stones,   146 
aureus  in  biliary  abscess,  87 

in  gall-stones,  146 
gall-stones  from,  36 
Steeple  temperature  chart,    133, 

190 
Sterilization  of  catgut,  280 
of  gloves,  275 
of  hands,  273 
of  instruments,  280 
of  ligatures,  280 
of  swabs,  279 
Stomach  and  gall-bladder,  fistula 
between,  208,  212 
diseases,    gall-stone   pain    and, 

114 
inflation  in  diagnosis  of  tumour 
of  gall-bladder,  136 
Stools  in  partial  occlusion  of  com- 
mon duct,  191 
Strangulation.     See  Intestinal  ob- 

stmction. 
Streptococcus  pyogenes  albus  in 
acute  cholecystitis,  163 
aureus  in  acute  cholecystitis, 
163 


Stricture  of  ducts  from  gall-stone 
disease,  93 

Subhepatic  hepaticostomy,  337 

Subphrenic  abscess  from  occlu- 
sion of  common  duct,  196 

Surgeon,  preparation  of,  for  oper- 
ation, 270 

Stiture  material  for  operations, 
280 

Suturing  abdominal  wovmd,  306, 

307 

Swabs  for  operations,  278 
placing  of,  303 
sterilization  of,  279 

Symptoms  of  gall-stone  disease, 
109.  See  also  Gall-stone  dis- 
ease, symptoms  of. 


Teeth,    cleansing   for   operation, 

285 
Temperature  chart,  steeple,   133, 
'   190 

in  gall-stone  disease,  132,   142 
in  partial  occlusion  of  common 
duct,   1S9,  190 
Tenderness  of  gall-bladder  in  gall- 
stone   disease,    iii,     112,     116, 

150 
Tetany  in  gall-stone  disease,  142 
Thoracic  organ  and  bile  passages, 

fistulae  between,  220 
Transhepatic  hepaticostomy,  337 
Tumours    in     gall-stone    disease, 

134 
of     gall-bladder,     inflation     of 
stomach  in  diagnosis,  136 
Typhoid       bacillus,       gall-stones 
from,  36,  39 
in  bile,  36,  39 
in  biliary  abscess,  87 
fever,  biliary  infection  and,  39 
gall-stone       disease       with, 

dangers  of ,  88 
suppurative  cholangitis  from, 
87 


25 


;86 


Index 


Ulceration  into  duodenum,  85 

of  gall-bladder,  67 
Urinary  and  bile   tracts,   fistulas 

between,  217 
Urine,   albumin  in,   in   gall-stone 
disease,  144 
examination   of,  before   opera- 
tion, 2  88 
in  partial  occlusion  of  common 
duct,  191 
Uterus,    fistulse   into,    from    gall- 
stone disease,  219 

Valves  of  Heister,  20 
Valvulse  conniventes,  22 
Varieties  of  gall-stones,  31 


Vater,  ampulla  of,  22,  26 
diverticulum  of,  22,  26 
V^olvulus  from  gall-stones,  255 
Vomiting    in    gall-stone    disease, 
123,  142 
in   intestinal   obstruction   from 
gall-stones,  258 
faecal,  259 
of  gall-stones,  210 


Weight,  loss  of,  from  stones  in 

common  duct,  192 
Winslow,  foramen  of,  23 
Wirsung,  canal  of,  22 
Wound,  closing  of,  306,  307 


JNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
fhis  book  is  DUE  on  the  last  date  stamped  below. 


fF3 


A     ^ 


